Richard Carpenter
25 Apr 2024 · Coroner David Ridley · Wiltshire and Swindon
This report repeats 3 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. ambulance response delays
“the pressures that all ambulance trusts were under at that particular time and he also explained new ways of working with a view to reducing the number of outstanding unallocated calls including the use of the National Model for Clinical Navigation and the use of ambulance personnel at hospital in an attempt to free up ambulances although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover”
2. delayed ambulance arrival
“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”
3. year-round ambulance service strain
“what used to be considered seasonal pressures on ambulance services during the winter months is now becoming an all year round norm”
Linked reports
Identical hazardConfidence 0.92 · high
Earlier report
“Evidence given at the inquest revealed that there was a delay in an ambulance attending to the deceased and that earlier arrival of an ambulance is likely to mean he would not have died when he did.”
This 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”
Identical hazardConfidence 0.90 · high
Earlier report
“long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future”
This 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
Earlier report
“The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time.”
This report
“although I did hear that it is not uncommon for around 30% of available ambulances to still be held up at hospitals in our area waiting for a handover.”
Closely relatedConfidence 0.80 · moderate
This 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”
Later report
“patients such as [the deceased] remain at risk. The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.”
Responses
2024-0221-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · 2023/24
“In January 2023, NHS England published a two year 'Delivery plan for recovering urgent and emergency care services' which aims to deliver sustained improvements in waiting times, with a target for this year to reduce Category 2 ambulance response times to 30 minutes on average.”