Sophie Hindmarsh
29 Apr 2024 · Coroner Hannah Berry · South Yorkshire West
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed ambulance response
“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
2. offloading delay
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The calls (999) to the ambulance service were properly coded and applied by the call-taker leading to a Green 2 response. This should have led to a vehicle attending within 20 minutes. In the event, the vehicle did not arrive for 2 hours 8 minutes.”
This report
“The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Identical hazardConfidence 0.92 · high
Earlier report
“Yorkshire Ambulance Service were unable to respond to [the deceased]'s call until 2 hours and 26 minutes had passed.”
This report
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call.”
Identical hazardConfidence 0.94 · high
This report
“The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
Later report
“I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day.”
Closely relatedConfidence 0.90 · high
This report
“There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that day and meant they were unable to respond to emergency calls.”
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.”
Responses
2024-0231-Response-from-DHSC.pdf ↗· NHS England
Stated action
“Your report raised concerns about ambulance response times by Yorkshire Ambulance Service NHS Trust (YAS) and hospital handover delays. You have appropriately shared your report and concerns with West Yorkshire Integrated Care Board and NHS England (NHSE). Departmental officials have made enquiries with NHSE and West Yorkshire Integrated Care Board who I understand will be writing to you directly on the specific actions being taken locally to improve ambulance response and handover times.”
2024-0231-Response-from-NHS-England.pdf ↗· NHS England
Stated action · 2023/24
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way at some NHS Trusts. NHS England prioritised improving ambulance performance during 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlined key actions to”
2024-0231-Response-from-West-Yorkshire-ICB.pdf ↗· West Yorkshire Integrated Care Board