Concerns raised 1
Continuing delays in ambulance handover and response View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kevin George Woods · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Continuing delays in ambulance handover and response
Wider context from the report “1) 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.
” Source location Kevin George Woods · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return to the NHS Constitution’s safe operational waiting-time standards.
Verbatim wording from the response “At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This reported on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare providers are responsible for identifying and mitigating risks within their services through their own patient-safety processes.
Verbatim wording from the response “The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.” Source location Response from DHSC
Open published response
20 Sep 2024 Susan Dear · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Delays in hospital handover of ambulance patients View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Improve hospital flow to reduce unnecessary hospital stays and delayed discharges.
View source
Department of Health and Social Care
Develop local NHS and social-care partnership working to tackle delayed discharges.
View source
Department of Health and Social Care
Ensure every acute hospital has access to a care transfer hub for complex discharges.
View source
Department of Health and Social Care
Work directly with health and social-care partners in systems facing the most discharge delays to drive improvements.
View source
NHS England
Improve hospital patient flow and reduce ambulance handover delays through discharge and provider-coordination measures.
View source
NHS England
Use Key Lines of Enquiry to help ambulance and acute providers identify opportunities to reduce handover delays and improve patient flow.
View source See 3 more actions
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AI-generated summary
Susan Dear · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in hospital handover of ambulance patients
Wider context from the report “(6) handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community; and
” Source location Susan Dear · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital flow to reduce unnecessary hospital stays and delayed discharges.
Verbatim wording from the response “Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS and social-care partnership working to tackle delayed discharges.
Verbatim wording from the response “Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure every acute hospital has access to a care transfer hub for complex discharges.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work directly with health and social-care partners in systems facing the most discharge delays to drive improvements.
Verbatim wording from the response “We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital patient flow and reduce ambulance handover delays through discharge and provider-coordination measures.
Verbatim wording from the response “Work has also focused on the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use Key Lines of Enquiry to help ambulance and acute providers identify opportunities to reduce handover delays and improve patient flow.
Verbatim wording from the response “Within Emergency Departments, the NHS standard contract states that all handovers of patients between ambulances and A&E must take place within 15 minutes, with none taking more than 30 minutes. The clock begins when an ambulance arrives outside an A&E department and stops when a clinical handover has been fully completed to A&E staff. Key Lines of Enquiry (KLOEs) have previously been developed by NHS England to support ambulance and acute providers to identify key opportunities to reduce ambulance handover delays and improve patient flow, as outlined in the UEC Recovery Plan (2023).” Source location Response from NHSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing ongoing handover delays rests with the responsible integrated care boards commissioning the hospital emergency department services.
Verbatim wording from the response “My regional colleagues are also in the process of engaging with Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (BOB ICB) and Frimley ICB,” Source location Response from NHSE
Open published response
15 Jul 2024 Josh Andrew Smith · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1
Failure to achieve the 15-minute ambulance hospital handover target View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Josh Andrew Smith · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Josh Andrew Smith had longstanding medical complications following quadriplegia from a 2009 road traffic incident. He was found unresponsive and not breathing on 19 December 2022, was diagnosed with hypoxic brain injury, bronchopneumonia and influenza A, and died on 22 December 2022 despite treatment. Concerns included continuing ambulance response delays and hospital handover delays, with response standards and the 15-minute handover target not being achieved.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to achieve the 15-minute ambulance hospital handover target
Wider context from the report “I heard evidenced that whilst the Yorkshire Ambulance Service have taken a number of steps within their powers to try to reduce the delays experienced by patients waiting for an ambulance within the community, that those delays continue.
Specifically, I was told that the response standards for both Category 1 and Category 2 calls (for the year to date), whilst improved from the time of Mr Smith’s death, still remain outside of the target response standards (both on average and at the 90ᵗʰ centile).
The evidence heard was that the national target for hospital handover by the ambulance service, of 15 minutes, is still not being achieved . Evidence suggested that whilst there has and continues to be efforts made by the ambulance service and acute hospitals to increase the speed at which ambulances handover their patients, that delays in this process continue to impact upon the speed of the ambulance response to patients waiting within the community .
” Source location Josh Andrew Smith · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Regulation 28 response, report and concerns with the Hull and East Riding Urgent and Emergency Care Transformation Programme.
Verbatim wording from the response “This response and the Regulation 28 report and matters of concern will be shared with Hull and East Riding Urgent and Emergency Care Transformation Programme. This oversees the local improvement of ambulance handover and delivery of timely responses in that community.” Source location Response from NHS West Yorkshire ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve patient flow through hospitals and reduce ambulance handover delays.
Verbatim wording from the response “National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Speed hospital discharges to support improved patient flow.
Verbatim wording from the response “National work has also focused on the need to increase ambulance capacity through growing the workforce, improve flow through hospitals and reduce handover delays, speed up discharges from hospital and expand new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The West Yorkshire Integrated Care Board is responsible for responding directly on local and system measures addressing patient flow and ambulance handover concerns.
Verbatim wording from the response “My regional colleagues in the North East & Yorkshire have also engaged with colleagues at the West Yorkshire Integrated Care Board (WYICB) in relation to your concerns, who have advised us of several measures underway to improve flow and ambulance delivery. I understand that WYICB are responding directly to the Coroner, and I refer you to their response for further information on local and system steps.” Source location Response from NHS England
Open published response
4 Jul 2024 Harry Peter DUNN · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Delays in clearing ambulances from Accident and Emergency departments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Harry Peter DUNN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Harry Peter Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raised concerns about the unavailability and delayed response of ambulance resources, including delays caused by lengthy hospital handovers, and the continuing risk of future deaths from these delays.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in clearing ambulances from Accident and Emergency departments
Wider context from the report “(1) When the 999 call was made shortly following the accident no resources were available within either the operating area of the relevant ambulance trust, East Midlands Ambulance Service Trust (“EMAS”) or within the neighbouring South Central Ambulance Service Trust. The only available emergency medical resource was that run by the Air Ambulance Service Charity which was an advanced medical team based out of Coventry Airport, some c.30 miles away with an estimated arrival time of 57 minutes.
(2) The Inquest heard that EMAS was unable to meet mean response standards at the time of the 999 call. They had entered a sustained period where demand was outstripping the resources they had available. This was worsened by the fact that what resources they did have were being delayed at hospitals due to lengthy hospital handovers at the Accident and Emergency departments .
(3) Although EMAS reported a slight improvement in the issue of resourcing following the adoption of the newer NHS Pathways triage process the delay in paramedics attending Category 2 calls has not been resolved to within target ranges. This is because EMAS’s resources cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments .
(4) I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.
” Source location Harry Peter DUNN · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce ambulance handover delays to support patient flow.
Verbatim wording from the response “In the shorter-term, a range of action is being taken by the NHS this year to improve performance including maintaining the increase in ambulance capacity (hours on the road) delivered in 2023/24, where NHSE reported a circa 6% increase year-on-year for December 2023. There is a focus on reducing ambulance handover delays to support patient flow and on increasing direct referrals into community services to reduce conveyance rates to acute hospitals.” Source location Response-from-DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase direct referrals into community services to reduce conveyance to acute hospitals.
Verbatim wording from the response “In the shorter-term, a range of action is being taken by the NHS this year to improve performance including maintaining the increase in ambulance capacity (hours on the road) delivered in 2023/24, where NHSE reported a circa 6% increase year-on-year for December 2023. There is a focus on reducing ambulance handover delays to support patient flow and on increasing direct referrals into community services to reduce conveyance rates to acute hospitals.” Source location Response-from-DHSC
Open published response
20 May 2024 Sylvia Eileen Evans · Prevention of Future Deaths report Gwent
View report summary
Concerns raised 1
Delays in hospital handover View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Aneurin Bevan University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Aneurin Bevan University LHB
Revise the escalation framework for ambulance handover delays.
View source
Aneurin Bevan University LHB
Improve discharge-lounge use to create capacity and support ambulance handover times.
View source
Aneurin Bevan University LHB
Hold weekly Patient Safety Flow meetings with defined action plans addressing patient flow and ambulance handover delays.
View source
Aneurin Bevan University LHB
Create a post supporting the Chief Operating Officer’s team to increase urgent-care operational and escalation capacity.
View source
Aneurin Bevan University LHB
Increase substantive Physician Response Unit provision to deliver community emergency medicine and reduce emergency-department conveyance.
View source
Aneurin Bevan University LHB
Improve Same Day Emergency Care services and increase patient selection to release emergency-department and assessment capacity.
View source
Aneurin Bevan University LHB
Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce discharge delays.
View source
Aneurin Bevan University LHB
Create a discharge hub at Royal Gwent Hospital jointly with social care.
View source
Aneurin Bevan University LHB
Create a Ready to Go Ward and discharge floor at Royal Gwent Hospital to coordinate discharge and transition home.
View source
Aneurin Bevan University LHB
Create a Hospital to Home service providing additional community support.
View source
Aneurin Bevan University LHB
Deliver a proactive discharge project with Monmouthshire Local Authority at Nevill Hall Hospital.
View source See 8 more actions
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AI-generated summary
Sylvia Eileen Evans · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sylvia Eileen Evans sustained an accidental leg wound at home on 5 September 2023, causing severe haemorrhage, and died at home the following day. She called for an ambulance at 22:56, but the call ended abruptly before the nature of her injuries was conveyed. An ambulance arrived at 07:45, almost 8 hours and 49 minutes after the call was registered, and the report identifies hospital handover delay as contributing in part to the delay.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in hospital handover
Wider context from the report “The correct procedure was adopted by the Welsh Ambulance Service and Sylvia was categorised as requiring an Amber 1 response. The inquest heard that Amber 1 is the second highest category, reserved for people who are likely to be suffering from a life-threatening emergency.
An ambulance eventually arrived at 07:45 on 06/09/2023. This was almost 8 hours and 49 minutes after the call was registered. Sylvia had died by the time the ambulance arrived.
The reason for the delay was explored at the inquest and in part determined to be due to hospital handover delay.
” Source location Sylvia Eileen Evans · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the escalation framework for ambulance handover delays.
Verbatim wording from the response “a. Revision of the escalation framework to ensure that the points of escalation during any ambulance handover delays are appropriate” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve discharge-lounge use to create capacity and support ambulance handover times.
Verbatim wording from the response “3. Discharge Logistics” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly Patient Safety Flow meetings with defined action plans addressing patient flow and ambulance handover delays.
Verbatim wording from the response “Recent initiatives to improve patient flow and subsequent ambulance handover delays saw the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following workstreams:” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a post supporting the Chief Operating Officer’s team to increase urgent-care operational and escalation capacity.
Verbatim wording from the response “2. A new post supporting the Chief Operating Officer’s team to enhance capacity and focus on the urgent care system daily operating and escalation where appropriate.” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase substantive Physician Response Unit provision to deliver community emergency medicine and reduce emergency-department conveyance.
Verbatim wording from the response “3. A number of priority developments being tested and considered as part of the improvement programme.:” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve Same Day Emergency Care services and increase patient selection to release emergency-department and assessment capacity.
Verbatim wording from the response “2. Workstream 2 - Urgent & Emergency Care Redesign” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce discharge delays.
Verbatim wording from the response “3. Workstream 3 - Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a discharge hub at Royal Gwent Hospital jointly with social care.
Verbatim wording from the response “b. Creation of a discharge hub at the Royal Gwent Hospital jointly with social care” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Ready to Go Ward and discharge floor at Royal Gwent Hospital to coordinate discharge and transition home.
Verbatim wording from the response “c. Creation of a Ready to Go Ward and a discharge floor at the Royal Gwent to bring together a discharge lounge, the Ready to Go Ward and an integrated hub to manage patients transition more effectively to their own home” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create a Hospital to Home service providing additional community support.
Verbatim wording from the response “d. Creation of a Hospital to Home service to provide additional support within the community” Source location Response from Aneurin Bevan University Health Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a proactive discharge project with Monmouthshire Local Authority at Nevill Hall Hospital.
Verbatim wording from the response “e. A focused project at Nevill Hall Hospital working with Monmouthshire Local Authority focused on proactive discharge arrangements to people’s own homes” Source location Response from Aneurin Bevan University Health Board
Open published response
8 May 2024 Bobilya Mulonge · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in ambulances clearing Accident and Emergency departments View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Bobilya Mulonge · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Mulonge became unconscious after developing laboured breathing on 24 November 2022 and was found in cardiac arrest when an ambulance arrived 72 minutes after the call. She died later that day from congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus; the principal concern was that delays in ambulance response times had not been resolved within target ranges because ambulances could not be cleared from Accident and Emergency departments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulances clearing Accident and Emergency departments
Wider context from the 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. This is because resources available in the North West Ambulance Service cannot be fully utilised as a result of the delays in ambulances clearing Accident and Emergency departments .
” Source location Bobilya Mulonge · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location 2024-0250 Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely and effective hospital discharge and reduce admission waits.
Verbatim wording from the response “To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location 2024-0250 Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in offloading ambulance patients at hospitals View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England NHS West Yorkshire Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Department of Health and Social Care
Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.
View source
Department of Health and Social Care
Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from A&E.
View source
NHS West Yorkshire Integrated Care Board
Implement quality-improvement initiatives with acute trusts to reduce ambulance handover delays.
View source
NHS West Yorkshire Integrated Care Board
Agree and use a Joint Escalation Action Plan defining organisational actions to improve ambulance handover during system pressures.
View source
NHS West Yorkshire Integrated Care Board
Introduce and enact a Duty to Rescue protocol enabling senior clinical decisions on rapid handover and ambulance release during significant operational pressure.
View source
NHS West Yorkshire Integrated Care Board
Develop and improve alternative care pathways, including Urgent Community Response and direct Same Day Emergency Care access, to avoid appropriate hospital conveyance.
View source
NHS England
Publish the Delivery plan for recovering urgent and emergency care services to improve ambulance and urgent-care performance.
View source See 4 more actions
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AI-generated summary
Sophie HINDMARSH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sophie HINDMARSH had complex needs and required full-time care. After her father called 999 because she was vomiting brown liquid, felt hot to the touch and had a leaking feeding tube, the ambulance arrived 4 hours and 46 minutes after the call; concerns centred on delays in ambulance response and hospital handovers that reduced available ambulance resources.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in offloading ambulance patients at hospitals
Wider context from the 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.
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 .
” Source location Sophie HINDMARSH · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.
Verbatim wording from the response “Your report highlights that YAS were under high demand at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from A&E.
Verbatim wording from the response “£1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement quality-improvement initiatives with acute trusts to reduce ambulance handover delays.
Verbatim wording from the response “The correlation between handover delays at Emergency Departments and overall ambulance response times is widely acknowledged. Handover times vary amongst our acute trusts in the region. We seek to ensure the root causes are understood.” Source location Response from West Yorkshire ICB
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Agree and use a Joint Escalation Action Plan defining organisational actions to improve ambulance handover during system pressures.
Verbatim wording from the response “YAS and Sheffield Teaching Hospitals (including other South Yorkshire Hospitals) have agreed a new Joint Escalation Action Plan (JEAP), for when system pressures increase. This plan provides specific actions that organisations must employ to support the improvement of ambulance handover.” Source location Response from West Yorkshire ICB
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce and enact a Duty to Rescue protocol enabling senior clinical decisions on rapid handover and ambulance release during significant operational pressure.
Verbatim wording from the response “Implementation of Duty to Rescue protocol - this protocol was introduced ahead of the winter period (2023/24) and is now enacted at times of significant operational pressure. On occasions when there are high number of ambulances waiting to handover patients, the protocol allows for senior clinical decision makers from YAS and our hospitals to agree to the rapid handover and timely release of an ambulance crew to attend to a specific 999 call, or one who has been awaiting conveyance and is deteriorating. The introduction of this protocol has been welcomed by all parties and allows for clinical risks to be better managed in the system.” Source location Response from West Yorkshire ICB
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and improve alternative care pathways, including Urgent Community Response and direct Same Day Emergency Care access, to avoid appropriate hospital conveyance.
Verbatim wording from the response “Alternatives to Accident and Emergency (A&E) Departments – more alternative pathways of care are available for use by YAS Ambulance crews or staff within the Emergency Operations Centre (EOC) to safely and appropriately avoid conveyance to hospital.” Source location Response from West Yorkshire ICB
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Delivery plan for recovering urgent and emergency care services to improve ambulance and urgent-care performance.
Verbatim wording from the response “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.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific actions to improve ambulance response and hospital handover times will be provided directly by NHS England and the Integrated Care Board.
Verbatim wording from the response “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.” Source location Response from DHSC
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25 Apr 2024 Richard Carpenter · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1
Delays in ambulance handover at hospitals View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Richard Carpenter · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “During the course of the Inquest I heard evidence from the Southwest Ambulance Trust from ████████ who is the Deputy Head of Clinical Operations in Safety and he explained in detail 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 .
” Source location Richard Carpenter · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “Your report highlights that SWAST were responding to high demand. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.
Verbatim wording from the response “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SWAST is best placed to determine and implement local action with NHS partners to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with SWAST, who are best placed to respond on the specific action they are taking locally with NHS system partners to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
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17 Apr 2024 Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Delays in hospital handover compromising ambulance crew availability View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Birmingham and Solihull Integrated Care Board NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
NHS Birmingham and Solihull Integrated Care Board
Coordinate system-wide urgent and emergency care responses through the Delivery and Improvement Board and System Co-ordination Centre, with escalation and safety oversight.
View source
NHS Birmingham and Solihull Integrated Care Board
Maintain accredited System Co-ordination Centre capability to coordinate pressure-point interventions, joined-up problem solving and safety across urgent and emergency care pathways.
View source
NHS Birmingham and Solihull Integrated Care Board
Review urgent treatment centre provision against local population needs and national guidance.
View source
NHS Birmingham and Solihull Integrated Care Board
Provide the “Call before you convey” service to divert suitable older patients from hospital attendance into urgent community or wider community services.
View source
NHS Birmingham and Solihull Integrated Care Board
Operate a single transfer-of-care hub approach with local partners to reduce handoffs and accelerate movement from acute hospitals into community services.
View source
NHS England
Engage weekly with Integrated Care Boards through assurance and planning rounds to reduce emergency department crowding, improve acute front-door services, and release ambulance capacity.
View source
NHS England
Drive further efficiencies in acute patient flow, same-day care, care closer to home, and avoidance of frail and elderly patients’ avoidable attendances.
View source
Department of Health and Social Care
Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 against 2022/23 plans.
View source
Department of Health and Social Care
Make £1.6 billion available over two years to support timely hospital discharge and reduce admission delays.
View source See 6 more actions
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Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in hospital handover compromising ambulance crew availability
Wider context from the report “1. During the inquest evidence was given on behalf of West Midlands Ambulance Service from ████████, Learning Response Lead, that at the time of Jade's initial call reporting centralised chest pain at 13:33 on the 31st May 2023 the Trust was experiencing increased volume of calls and significant hospital delays and therefore could not resource the category 2 disposition within national target times (mean average of 18 minutes, 90th centile of 40 minutes). The call was still unresourced when she was reported to be in cardiac arrest during a further call at 15:01 (the 4th call). The Trust's Gold Dashboard that was captured closest to the clock start time for the first call (captured at 13:00:32) identified that there were delays in the mean and 90th percentile response times for Category 1, 2, 3 calls. There was 3 available ambulance resource within the sector at that point in time with 54 Category 2 and 43 Category 3 cases awaiting resource allocation, and 16 cases yet to be prioritised. There were regional hospital delays of up to 218 minutes.
2. For the 2 hours before Jade's call the Birmingham sector had been experiencing a 2 hour spike in demand. However, the real problem affecting resourcing was pandemic crews being stuck at hospitals awaiting handover . In 2023 to 2024 West Midlands Ambulance Service lost approximately 250,000 response hours due to delays at hospitals .
3. West Midlands Ambulance Service have taken a broad range of measures in recent years to tackle increasing response times including measures to reduce call demand through public education, to avert calls away from ambulance services and hospitals via clinical validation, to improve patient flow through intelligent conveying and to increase the number of resources in operation. Aside from seeking funding to recruit further paramedics and increase ambulance numbers alongside continued monitoring and learning there is nothing West Midlands Ambulance Service can identify that they can do to improve the situation further.
4. West Midlands Ambulance Service continue to fail to meet target response times and have been made the subject of a regulation 12 notice on this topic by the CQC.
5. The evidence of West Midlands Ambulance Service is that if hospital handover delays didn’t exist they would be likely to be meeting their response targets as they did before hospital delays became chronic.
In the circumstances it is my conclusion that the availability of ambulance crews is continuing to be compromised by delays at hospitals resulting in delays in response times which creates a risk to the life.
” Source location Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Coordinate system-wide urgent and emergency care responses through the Delivery and Improvement Board and System Co-ordination Centre, with escalation and safety oversight.
Verbatim wording from the response “For this reason, oversight is via a UEC Delivery and Improvement Board which is chaired by the ICB Chief Delivery Officer with senior representation from all system partners. This Board provides integrated system leadership to set and deliver the Urgent and Emergency Care Strategy, with a focus on equity of access and system efficiency.” Source location Response from NHS Birmingham and Solihull
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain accredited System Co-ordination Centre capability to coordinate pressure-point interventions, joined-up problem solving and safety across urgent and emergency care pathways.
Verbatim wording from the response “The ICB hosts the SCC, which holds full accreditation status from NHS England in compliance with the national SCC specification. The team are responsible for co-ordinating the system-wide response to pressure points, such as ambulance handovers and increases of activity in EDs, and supporting interventions in all pathways. They have access to a wide range of data to enable their role and bring system partners together throughout the day, and into the out-of-hours period, to ensure joined up problem solving, effective flow and maintenance of safety.” Source location Response from NHS Birmingham and Solihull
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review urgent treatment centre provision against local population needs and national guidance.
Verbatim wording from the response “BSOL has six UTCs across the footprint; these can be accessed either by walking-in or via direction from NHS 111. They provide an alternative pathway away from ED for those patients who require swift medical attention with urgent but non-life-threatening conditions. The UTCs can also offer clinical telephone advice to ambulance crews on the scene and can accept conveyances when and where agreed. On average, 714 patients have been treated daily within UTCs over the last 12 months. A full review of UTC provision was instigated in May 2024 to ensure it meets the needs of both our local population and new national guidance published in October 2023.” Source location Response from NHS Birmingham and Solihull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the “Call before you convey” service to divert suitable older patients from hospital attendance into urgent community or wider community services.
Verbatim wording from the response “‘Call before you convey’ is a direct service available to WMAS colleagues whilst with the patient in their own home, offering diversion pathways to use where appropriate, other than hospital attendance. This service is primarily aimed to support patients over the age of 75 years, offering diversion into the UCR or wider community services. Since the commencement of this service in December 2023 there have been an average of just over 65 calls per week equating to nearly 10 patients per day.” Source location Response from NHS Birmingham and Solihull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a single transfer-of-care hub approach with local partners to reduce handoffs and accelerate movement from acute hospitals into community services.
Verbatim wording from the response “A single transfer of care hub approach was implemented by UHB, BCHC, Birmingham City Council and Solihull Metropolitan Borough Council in May 2024 to improve the flow of patients out of the acute hospital and into community services. The new process enables fewer handoffs between teams and will enable hospitals to ‘free up’ beds earlier, and therefore, admit patients from ED in a more timely way.” Source location Response from NHS Birmingham and Solihull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage weekly with Integrated Care Boards through assurance and planning rounds to reduce emergency department crowding, improve acute front-door services, and release ambulance capacity.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Drive further efficiencies in acute patient flow, same-day care, care closer to home, and avoidance of frail and elderly patients’ avoidable attendances.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 against 2022/23 plans.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely hospital discharge and reduce admission delays.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. To improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans. £1.6 billion of funding was also made available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ambulance service commissioning is undertaken by Black Country ICB on behalf of West Midlands ICBs, with BSOL as an associate commissioner.
Verbatim wording from the response “WMAS is not directly commissioned by BSOL, but by the Black Country ICB on behalf of the West Midlands ICBs, with BSOL as associate commissioners. As such BSOL contributes to discussion on performance and quality via established routes with Black Country colleagues. Operationally, however, WMAS colleagues are very integrated into BSOL provision and daily oversight rhythm. This not only includes the paramedic crews themselves, but presence of a senior co-ordinating role, the Hospital Ambulance Liaison Officer (HALO), and until recently provision within UHB with Ambulance Decision Areas (as below). The overall objective of the HALO service is to facilitate the handover of patients presenting at ED by ambulance, in a clinically safe, effective and efficient manner, thus enabling crews to turnaround ambulances in readiness to respond to other emergency calls.” Source location Response from NHS Birmingham and Solihull
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for improving ambulance handover delays rests with providers, commissioning bodies and regulators.
Verbatim wording from the response “Improving ambulance handover delays is the responsibility of all providers, commissioning bodies (Integrated Care Boards (ICBs)) and regulators. This year (2024/25) NHS England, through regular assurance and planning rounds, are engaging with ICBs on a weekly basis until assurance has been given that everyone is working to reduce emergency department crowding, improve acute front door services and release the ambulance service/s within their commissioned frameworks for 2024/25. In addition, throughout 2024/25 further work will be done to enhance and drive further efficiencies in acute patient flow, avoidable attendance for the frail and elderly emphasising same day care and care closer to home as a priority and this will aim to further improve the quality and standard of care across the emergency unscheduled care pathway.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England and the Birmingham Integrated Care Board are best placed to address local ambulance response and hospital handover delays.
Verbatim wording from the response “Your report raised concerns about ambulance response times at the West Midlands Ambulance Service (WMAS) University NHS Foundation Trust, and the hospital handover delays that they experience. You have appropriately shared your report and concerns with NHS England and Birmingham Integrated Care Board who are best placed to respond on the specific action being taken locally to improve ambulance response and handover times. You also shared your report with the Care Quality Commission who I note inspected WMAS in February 2024 and, while rating the trust good overall, raised the need to improve response times.” Source location Response from DHSC
Open published response
Concerns raised 1
Delays in ambulance-to-hospital patient handover View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
PATRICIA ANNE VAN DER EYKEN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by preventing lifesaving treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance-to-hospital patient handover
Wider context from the report “8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. This leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department. It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The report stated:
“It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance”.
9. The investigation report states
‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents . With fewer resources on the road, the response times to patients inevitably increases…
….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.”
10. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.
” Source location PATRICIA ANNE VAN DER EYKEN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1 billion to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.
Verbatim wording from the response “Your report highlights that SWAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specific actions to reduce handover delays and improve ambulance response times are best undertaken locally by SWAST and Royal Cornwall Hospital.
Verbatim wording from the response “Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) in particular how this impacted by handover delays and issues with discharging patients from hospital.” Source location Response from Department of Health and Social Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.