Lynda Blackmore
15 Nov 2023 · Coroner Graeme Hughes · South Wales Central
This report repeats 5 earlier warnings, and was raised again 15 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance handover
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
2. excessive handover delays
“handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“Finally, I was made aware that one of the key problems in ensuring ambulance availability is delayed handover of patients at hospitals.”
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Closely relatedConfidence 0.90 · high
Earlier report
“The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits. The evidence showed that the main reason for the delay was the significant hand over delays being experienced at the 2 district general hospitals”
This report
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Identical hazardConfidence 0.92 · high
Earlier report
“unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Closely relatedConfidence 0.90 · high
Earlier report
“Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow”
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Closely relatedConfidence 0.90 · high
Earlier report
“This risk is due firstly to a lack of available staff to provide the required operational hours and secondly to handover delays at hospitals across the region.”
This report
“As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016.”
Identical hazardConfidence 0.90 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
Identical hazardConfidence 0.90 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Closely relatedConfidence 0.90 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals.”
Closely relatedConfidence 0.92 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Later report
“Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances.”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances.”
Identical hazardConfidence 0.95 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Response times for ambulances attending acute medical incidents continue to be impacted by severe delays in patient handovers at acute hospitals preventing ambulances and their crews returning to service.”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Later report
“the main reason for the delay in dispatching emergency ambulances remains the length of time it is taking for ambulances to be released from the emergency department”
Identical hazardConfidence 0.90 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment”
Later report
“delays in ambulances clearing ED was still having a very significant impact on their ability to respond to calls”
Closely relatedConfidence 0.90 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“However, at the same time, the longest handover time at Northampton General Hospital was 5 hours and at Kettering General Hospital it was 7 hours.”
Identical hazardConfidence 0.94 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand.”
Identical hazardConfidence 0.92 · high
This report
“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital”
Later report
“Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available”
Identical hazardConfidence 0.90 · high
This report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Later report
“Significant handover delays 1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
Responses
2024-0062-Response-from-Nation-Institute-for-Health-and-Care-Excellence.pdf ↗· Aneurin Bevan University Health Board
Stated action
“We have produced several guidelines to help clinicians treating children presenting with fever and symptoms such as those in the case of [name redacted]. These include; fever in under 5s: assessment and initial management [NG143], sepsis: recognition, diagnosis and early management [NG51] and sore throat (acute): antimicrobial prescribing [NG84].”
2024-0069-Response-from-Aneurin-Bevan-University-Health-Board.pdf ↗· Aneurin Bevan University Health Board
Stated action
“have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”
2024-0069-Response-from-Welsh-Ambulance-Services-NHS-Trust.pdf ↗· Welsh Ambulance Service NHS Trust
Stated action · January 2024
“these, we have agreed some additional measures that we will be implementing in January 2024. These measures are expected to reduce the number of conveyances to The Grange Hospital through direct admission to alternative sites and the introduction of a new temporary facility that can be used for patients who are often those that experience the longest delay in handover.”