Michael Bray
22 May 2023 · Coroner Peter Taheri · Suffolk
This report repeats 2 earlier warnings, and was raised again 7 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance response to Category 2 calls
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges because there are residual staff and emergency vehicle shortages.”
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.”
Identical hazardConfidence 0.90 · high
Earlier report
“target response times are still routinely not being met nationally.”
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future.”
Closely relatedConfidence 0.85 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“The ambulance response time of 3 hours and 18 minutes has likely affected the outcome.”
Closely relatedConfidence 0.85 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“The category 2 call target (18minute average response and 95th percentile a 40minute response) was breached and the ambulance arrived 1 hour and 6 minutes after the first call.”
Closely relatedConfidence 0.85 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges”
Identical hazardConfidence 0.92 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes)”
Identical hazardConfidence 0.90 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion”
Closely relatedConfidence 0.90 · high
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“Despite a number of measures being undertaken by the North West Ambulance Service, the delay in paramedics attending Category 2 calls has not been resolved to within target ranges.”
Closely relatedConfidence 0.80 · moderate
This report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
Later report
“Demand outstripped capacity. An ambulance should have reached [the deceased] within two hours but it took five and half.”
Responses
2024-0238-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 2023/24
“published our Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times to 30 minutes on average this year”
2024-0238-Response-from-East-of-England-Ambulance-Service.pdf ↗· East of England Ambulance Service NHS Trust