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recurance

Peter Parker

22 Oct 2024 · Coroner Aled Gruffydd · SWANSEA NEATH & PORT TALBOT

This report repeats 8 earlier warnings, and was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. ambulances waiting at Emergency Departments to hand over patients

    “significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”

Linked reports

Repeats an earlier warningPamela Conway26 Aug 2016 · 8 years 2 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“there remain wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”
Original on judiciary.uk ↗

This report

“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningCeriann Richards1 Mar 2017 · 7 years 8 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“(1) The delay in an ambulance being despatched to the home address of the deceased who was clearly experiencing seizures/fits.”
Original on judiciary.uk ↗

This report

“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”
Full chain: Ambulance handover delay due to hospital capacity issues
Repeats an earlier warningLilly Baxandall17 May 2017 · 7 years 5 months earlier
Identical hazardConfidence 0.90 · 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”
Original on judiciary.uk ↗

This report

“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningRichard Barrett30 Jul 2018 · 6 years 3 months earlier
Closely relatedConfidence 0.80 · moderate

Earlier report

“The target turnaround time for ambulances at A&E is wildly unrealistic.”
Original on judiciary.uk ↗

This report

“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients,”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningMadeline Staples11 Feb 2019 · 5 years 8 months earlier
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”
Original on judiciary.uk ↗

This report

“ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance.”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningJean Frickel21 Jun 2023 · 1 year 4 months earlier
Identical hazardConfidence 0.92 · high

Earlier report

“ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.”
Original on judiciary.uk ↗

This report

“the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance's duty of care, and therefore not responding to emergency calls as is their purpose.”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningLynda Blackmore15 Nov 2023 · 11 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
Original on judiciary.uk ↗

This 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.”
Full chain: Ambulance handover delays due to bed shortages
Repeats an earlier warningJoseph Cattle22 Feb 2024 · 8 months earlier
Closely relatedConfidence 0.90 · high

Earlier report

“Despite having their full complement of ambulance resources staffed and on shift many of them were held up by delays in handover at hospitals;”
Original on judiciary.uk ↗

This report

“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients,”
Full chain: Ambulance handover delay due to hospital capacity issues
Raised again laterJeanette Sidlow Beech29 May 2025 · 7 months later
Closely relatedConfidence 0.90 · high

This report

“During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients”

Later report

“It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged”
Original on judiciary.uk ↗
Full chain: Ambulance handover delay due to hospital capacity issues

Responses

2024-0565-Response-from-Welsh-Government.pdf ↗· Welsh Government

Stated action · December 2024

“Welsh Government has set a priority for improvement in patient flow and the reduction of delayed discharges (pathways of care delays). To build on this, the Welsh Government has also set health boards in-year aspirations in 2024/2025 to reduce ambulance patient handovers over 1 hour by 30% by December 2024”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error