Recurring concern

Delays in ambulance-to-hospital patient handover

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First reported 21 Jan 2014•Latest report 18 Jun 2026

Definition

What this concern includes

Includes delays, target failures, capacity pressures, admission barriers and ineffective improvement measures that directly concern the ambulance-to-hospital patient handover process.

Not included

Excludes delays in ambulance response that are not directly linked to hospital handover.
Excludes generic hospital staffing, social care, patient-flow or capacity deficiencies unless the report directly ties them to ambulance-to-hospital handover delays.
Excludes clinical handover failures between hospital wards or other services that do not concern ambulance-to-hospital patient transfer.
Excludes safety monitoring and clinical care while a patient waits where the assertion does not itself identify delayed handover.

Reports: 77
Individual concerns: 86
Date range: 2014–2026
Stated actions: 337

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care43

Welsh Ambulance Services NHS Trust20

NHS England18

Betsi Cadwaladr University LHB14

Welsh Government9

Aneurin Bevan University LHB4

Care Quality Commission4

Conwy County Borough Council4

Denbighshire County Council4

Flintshire County Council4

NHS West Yorkshire Integrated Care Board4

Wrexham County Borough Council4

East Midlands Ambulance Service NHS Trust3

Gwynedd Council3

Isle of Anglesey County Council3

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Nov2019
North Wales (East and Central)
Concerns raised1
1. Failure to provide timely ambulance handover and admission
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Peter Andrew Connelly · 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

Peter Andrew Connelly was transferred to hospital on 19 February 2018, waited several hours for admission and medical examination, was diagnosed with acute pancreatitis, and died on 20 February 2018. The principal concern was continuing extreme pressure and delays in emergency department admission and treatment, which the report stated could place patients’ lives at risk and lead to preventable deaths; the delay was accepted not to have caused or contributed to Mr Connelly’s death.

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 provide timely ambulance handover and admission
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”. In the intervening period from then until the present either I or my Assistant Coroners have issued at least twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAST (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail. As has been stated previously in my other reports, I recognise that the issues which cause these difficulties are multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients’ lives are being placed at risk and this is wholly unacceptable.” Notwithstanding the fact that Mr Connelly’s death preceded the said February 2019 report and that there has been a reduction in the number of hours which ambulances were kept waiting outside ED since his death, the evidence which I heard at his inquest informed me that the ED at the Maelor Hospital, Wrexham continues to operate under extreme pressures and at an average scale of escalation (namely 3.1) which I consider is a clear indication that the various factors which cause delays in admission to hospital, have not been eliminated. Consequently it remains the case that delays in treatment may occur along with deaths which should be preventable by timely medical intervention. ”
Source location
Peter Andrew Connelly · Prevention of Future Deaths report
Page 1 · concerns
Open source report
12 Sep2019
Manchester North
Concerns raised1
1. Delays in hospital patient handover causing prolonged ambulance unavailability
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Use live electronic patient-tracking and ambulance turnaround displays to direct emergency-department workflow and support operational oversight.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Hold three daily senior-staff bed meetings that review live ambulance turnaround times.
  Stated by Stockport NHS Foundation TrustStated completed
3. Action
  Provide 24 additional Emergency Department trolleys to enable timely transfer of patients from ambulance trolleys.
  Stated by Stockport NHS Foundation TrustStated completed
1. Action
  Stream GP-referred patients arriving by ambulance directly to the Ambulatory Care Unit, bypassing Emergency Department admission.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Enable Emergency Department operational and administrative staff to participate in the regional ambulance handover collaborative project.
  Stated by Stockport NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Ambulance turnaround delays were not significantly different from other nights or uncommon.
  Stated by Stockport NHS Foundation TrustDisputes the concern
AI-generated summary

William Oliver · 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

William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.

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 patient handover causing prolonged ambulance unavailability
Wider context from the report
“2. Turnaround times at Greater Manchester Hospitals Another contributing factor to the decreased availability of ambulances on the 31st October - 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites. Whilst all hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester hospital, Royal Oldham, Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour. In total from the commencement of the night shift on the 31st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. The evidence from NWAS did not suggest this was significantly different to other nights or uncommon. ”
Source location
William Oliver · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 live electronic patient-tracking and ambulance turnaround displays to direct emergency-department workflow and support operational oversight.

Verbatim wording from the response
“The following actions have been put in to place to ensure ambulance crews can be released from the hospital:”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 12 September 2019
Open published response
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 three daily senior-staff bed meetings that review live ambulance turnaround times.

Verbatim wording from the response
“• The trust holds three bed meetings each day chaired and attended by senior trust staff. One of the key metrics reviewed as part of this meeting is the current live turnaround time for ambulances from our Emergency Department.”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 12 September 2019
Open published response
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 24 additional Emergency Department trolleys to enable timely transfer of patients from ambulance trolleys.

Verbatim wording from the response
“• We have also purchased 24 additional trolleys for the Emergency Department to ensure equipment availability to transfer patients from the ambulance trolley’s to enable crews to be released in a timely manner.”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 12 September 2019
Open published response
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
Stream GP-referred patients arriving by ambulance directly to the Ambulatory Care Unit, bypassing Emergency Department admission.

Verbatim wording from the response
“• Patients referred to the hospital by their GP who attend via ambulance can be streamed directly to our Ambulatory Care Unit, which by-passes an Emergency Department admission.”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 12 September 2019
Open published response
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
Enable Emergency Department operational and administrative staff to participate in the regional ambulance handover collaborative project.

Verbatim wording from the response
“• On October 25th 2019 Stockport NHS Foundation Trust was invited to join a Phase 2 NWAS ambulance handover collaborative project which will be looking at shared learning from across the region. The trust is delighted to have been invited to take part, and have ensured our engagement by enabling staff from our Emergency Department operational and administrative teams to engage in this collaborative.”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 12 September 2019
Open published response
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
Ambulance turnaround delays were not significantly different from other nights or uncommon.

Verbatim wording from the response
“Turnaround Times at Greater Manchester Hospitals Another contributing factor to the decreased availability of ambulances on the 31st October – 1st November 2018 was the turnaround times from hospitals in the Greater Manchester area. This was greater than anticipated at numerous sites. Whilst all hospitals were busy the turnaround times at Manchester Royal Infirmary, North Manchester General hospital, Royal Oldham, Salford Royal and Stepping Hill hospital were all particularly higher than anticipated with numerous ambulances delayed for over one hour. In total from the commencement of the night shift on the 31st October more than 273 hours of ambulance availability were spent at hospital sites handing over patients. The evidence from NWAS did not suggest this was significantly different to other nights or uncommon.”

Source location
2019-0494-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 12 September 2019
Open published response
11 Feb2019
North Wales (East and Central)
Concerns raised1
1. Delays in handover of patients at emergency departments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Madeline Constance Staples · 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

Madeline Constance Staples, an 86-year-old woman, suffered an unwitnessed fall at her care home on 6 April 2018, sustaining fractures to both legs. Delays in obtaining ambulance assistance and transporting her to hospital meant she remained in pain for several hours. The report raised concerns about repeated unacceptable delays linked to emergency department handovers and unavailable ambulance resources, placing patients’ lives at risk.

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 handover of patients at emergency departments
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in “unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls”. In the intervening period from then until the present either I or my Assistant Coroners have issued at least a further twelve similar regulation 28 reports expressing concerns associated with unacceptable delays and yet despite being given assurances in the responses to the same by BCUHB and WAS T (and other organisations) that action is being taken to reduce such delays, the situation continues to prevail. As has been stated previously in my other reports, I recognise that the issues which cause these difficulties is multifactorial, however unless services and resources are made available or working practices altered to facilitate change then it is inevitable that future deaths will occur which might have otherwise been preventable. Patients' lives are being placed at risk and this is wholly unacceptable. ”
Source location
Madeline Constance Staples · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Dec2018
Gwent
Concerns raised1
1. Excessive delays at hospitals
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Reduce hospital handover duration to release staff for further responses.
  Stated by Welsh Ambulance Services NHS TrustStatus unclear
2. Action
  Reduce conveyance where safe and provide appropriate care at home using advanced practitioners.
  Stated by Welsh Ambulance Services NHS TrustStatus unclear
3. Action
  Work with Welsh Ambulance Services Trust colleagues to improve hospital ambulance handover times.
  Stated by Aneurin Bevan University LHBStated in progress
1. Action
  Use Emergency Department escalation protocols to manage delayed ambulance crews and create offloading capacity.
  Stated by Aneurin Bevan University LHBStated completed
2. Action
  Use the Full Capacity Protocol to trigger patient moves that facilitate immediate ambulance handover.
  Stated by Aneurin Bevan University LHBStated completed
3. Action
  Use the Red Release Protocol to identify an urgent patient move when an ambulance crew is needed for a red community call.
  Stated by Aneurin Bevan University LHBStated completed
4. Action
  Operate the Winter Resilience plan to manage winter demand and capacity pressures affecting ambulance release.
  Stated by Aneurin Bevan University LHBStated completed
5. Action
  Have practitioners review WAST calls awaiting hospital attendance to direct patients to the most appropriate setting.
  Stated by Aneurin Bevan University LHBStated completed
6. Action
  Provide additional Emergency Department and Assessment Unit doctors to support timely patient assessment.
  Stated by Aneurin Bevan University LHBStated completed
7. Action
  Open additional capacity to meet predicted demand and support ambulance release.
  Stated by Aneurin Bevan University LHBStated completed
AI-generated summary

Diane Greenslade · 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

Diane Greenslade was found moaning on her bedroom floor with a chest of drawers on top of her after ambulance responses were delayed. She suffered a cardiac arrest and died, with the inquest concluding that she died from natural causes following a fifteen-and-a-half-hour delay in ambulance intervention. The substantive concerns included the initial call categorisation without clinical assessment, failure to consider escalation or a police welfare check, high ambulance demand and hospital delays, and a nearby rapid response vehicle being unavailable because it was reserved for higher-priority calls.

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
Excessive delays at hospitals
Wider context from the report
“(3) Demand for ambulances was high compounded by excessive delays at hospitals. ”
Source location
Diane Greenslade · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 hospital handover duration to release staff for further responses.

Verbatim wording from the response
“• Reducing the duration of handover to clear i.e. the time it takes for our staff to become available following the handover of a patient to another care provider, generally hospital staff”

Source location
2018-0401-Response-by-Welsh-Ambulance-Services
Page 2 · response
Published 21 December 2018
Open published response
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 conveyance where safe and provide appropriate care at home using advanced practitioners.

Verbatim wording from the response
“• Reducing conveyance where safe and appropriate, and providing care in the patient’s home utilising advanced practitioners”

Source location
2018-0401-Response-by-Welsh-Ambulance-Services
Page 2 · response
Published 21 December 2018
Open published response
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 with Welsh Ambulance Services Trust colleagues to improve hospital ambulance handover times.

Verbatim wording from the response
“The ability to release ambulance crews in order to respond to community calls is of paramount importance to Aneurin Bevan University Health Board (ABUHB) and we are working closely with our Welsh Ambulance Services Trust (WAST) colleagues to improve handover delays.”

Source location
2018-0401-Response-by-University-Health-Board
Page 1 · response
Published 21 December 2018
Open published response
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 Emergency Department escalation protocols to manage delayed ambulance crews and create offloading capacity.

Verbatim wording from the response
“As a Health Board, we have reviewed and implemented a number of key processes which should, in turn, improve the timeliness of releasing crews at the hospital. The Health Board has identified escalation protocols which are used to guide staff within the Emergency Department (ED) in the operational procedures for receiving and offloading ambulances. These include escalation when 3 or more crews are delayed for greater than 30 minutes and limited capacity exists within the hospital to off load them.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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 the Full Capacity Protocol to trigger patient moves that facilitate immediate ambulance handover.

Verbatim wording from the response
“The Health Board has a Full Capacity Protocol which lists a number of objectives to guide staff to trigger a list of actions, with the overall objective, to secure and maintain the safety of patients and staff within the ED and Assessment Units. This is to allow patient moves which facilitate the immediate handover of ambulances.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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 the Red Release Protocol to identify an urgent patient move when an ambulance crew is needed for a red community call.

Verbatim wording from the response
“The Health Board also has a Red Release Protocol for response to WAST, for when a crew is required to attend a ‘red’ call in the community. The identification of a ‘red release’ bed is discussed and agreed at each operational site meeting and a patient is identified as the urgent next move from ED, should the need to respond to a red release is called.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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
Operate the Winter Resilience plan to manage winter demand and capacity pressures affecting ambulance release.

Verbatim wording from the response
“The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board’s Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital. For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting. We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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
Have practitioners review WAST calls awaiting hospital attendance to direct patients to the most appropriate setting.

Verbatim wording from the response
“The Health Board has a Winter Resilience plan which is designed to manage the peaks of demand and capacity through the winter period when services are under significant pressure. The plan was developed with stakeholders and partners to ensure actions and initiatives described within the plan are shared, agreed and delivered in partnership. The plan is monitored by all stakeholders, including WAST, on a weekly basis and also reviewed and monitored by the Health Board’s Executive Team each week. There are several initiatives included in the plan which support the timely release of ambulances at the hospital. For example, we have practitioners reviewing the WAST calls waiting to attend the hospital to ensure patients are treated in the most appropriate setting. We will shortly be implementing clinical call handlers assessing GP calls for admission to hospital.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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 additional Emergency Department and Assessment Unit doctors to support timely patient assessment.

Verbatim wording from the response
“We have additional doctors in the Emergency Department and on our Assessment Units to ensure more timely assessment of patients, and we have opened additional capacity in order to meet the predicted demand. There are several other initiatives to support the winter pressures to reduce demand, and improve our flow in order to release ambulances.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
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
Open additional capacity to meet predicted demand and support ambulance release.

Verbatim wording from the response
“We have additional doctors in the Emergency Department and on our Assessment Units to ensure more timely assessment of patients, and we have opened additional capacity in order to meet the predicted demand. There are several other initiatives to support the winter pressures to reduce demand, and improve our flow in order to release ambulances.”

Source location
2018-0401-Response-by-University-Health-Board
Page 2 · response
Published 21 December 2018
Open published response
30 Jul2018
South Wales Central
Concerns raised1
1. Unrealistic target turnaround time for ambulances at A&E
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Direct health board chief executives to reduce and eradicate ambulance handover delays through coordinated patient-flow improvements and alternative unscheduled-care pathways.
  Stated by Welsh GovernmentStated completed
2. Action
  Monitor patient handover delays daily and challenge health boards where appropriate.
  Stated by Welsh GovernmentStated completed
Respondent positions 1
1. Position
  Health boards are responsible for reducing patient handover delays, improving hospital flow and receiving ambulance patients safely and promptly.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Mr Richard Thomas Peter Barrett · 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

On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.

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
Unrealistic target turnaround time for ambulances at A&E
Wider context from the report
“(3) The target turnaround time for ambulances at A&E is wildly unrealistic. Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes. Such delay must have a knock-on effect upon the ‘demand analysis’. ”
Source location
Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Direct health board chief executives to reduce and eradicate ambulance handover delays through coordinated patient-flow improvements and alternative unscheduled-care pathways.

Verbatim wording from the response
“We expect health boards to monitor all patients, especially those with time-critical and acute conditions or injuries to ensure they are handed over to the care of specialist staff as soon as possible, in order to improve patient outcomes and manage the associated risk. The Cabinet Secretary has also been clear with health board chief executives that they must take responsibility to reduce and eradicate patient handover delays by working with the Welsh ambulance service and partner organisations to improve patient flow through hospitals and receive patients from ambulance crews in a safe and timely manner. In addition they must explore alternative pathways and be able to divert demand to other unscheduled care services to reduce pressure at emergency departments during busy periods.”

Source location
2018-0249-Response-by-Welsh-Government
Page 2 · response
Published 24 September 2018
Open published response
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
Monitor patient handover delays daily and challenge health boards where appropriate.

Verbatim wording from the response
“It should be noted that there is no time-based target for the handover of patients from ambulance crews to emergency department staff. However, the Welsh Health Circular on NHS Wales Hospital Handover Guidance, published in May 2016, sets out good practice for patient handover, including an expectation for patients to be handed over within 15 minutes. Officials continue to monitor patient handover delays closely on a daily basis and challenge health boards where appropriate.”

Source location
2018-0249-Response-by-Welsh-Government
Page 2 · response
Published 24 September 2018
Open published response
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
Health boards are responsible for reducing patient handover delays, improving hospital flow and receiving ambulance patients safely and promptly.

Verbatim wording from the response
“We expect health boards to monitor all patients, especially those with time-critical and acute conditions or injuries to ensure they are handed over to the care of specialist staff as soon as possible, in order to improve patient outcomes and manage the associated risk. The Cabinet Secretary has also been clear with health board chief executives that they must take responsibility to reduce and eradicate patient handover delays by working with the Welsh ambulance service and partner organisations to improve patient flow through hospitals and receive patients from ambulance crews in a safe and timely manner. In addition they must explore alternative pathways and be able to divert demand to other unscheduled care services to reduce pressure at emergency departments during busy periods.”

Source location
2018-0249-Response-by-Welsh-Government
Page 2 · response
Published 24 September 2018
Open published response
29 Mar2018
Hertfordshire
Concerns raised1
1. Delays in handover to hospital
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 14
1. Action
  Deploy Patient Safety Intervention Teams to emergency departments experiencing prolonged ambulance handover delays.
  Stated by East of England Ambulance Service NHS TrustStated completed
2. Action
  Collaborate with acute-sector organisations and Clinical Commissioning Groups to resolve hospital handover delays.
  Stated by East of England Ambulance Service NHS TrustStated in progress
3. Action
  Reconfigure ambulance handover using lean principles to remove non-essential tasks and reduce handover times.
  Stated by East and North Hertfordshire Teaching NHS TrustStated completed
1. Action
  Conduct a June 2018 focus week using the previous improvement methods to restore ambulance handover performance.
  Stated by East and North Hertfordshire Teaching NHS TrustStated in progress
2. Action
  Monitor ambulance handover performance weekly after implementing the improvements.
  Stated by East and North Hertfordshire Teaching NHS TrustStated planned
3. Action
  Maintain contingency capacity by operating an additional ward and surgical outlier bays to mitigate emergency-department overcrowding and ambulance offload delays.
  Stated by Luton and Dunstable University HospitalStated completed
4. Action
  Transfer existing emergency-department patients into hospital and assessment beds to prioritise cubicle space for arriving ambulance patients.
  Stated by Luton and Dunstable University HospitalStated planned
5. Action
  Open further contingency areas as necessary to proactively create emergency-department capacity and reduce ambulance offload delays.
  Stated by Luton and Dunstable University HospitalStated planned
6. Action
  Board patients on wards by transferring them before beds become available, temporarily increasing ward capacity.
  Stated by Luton and Dunstable University HospitalStated planned
7. Action
  Introduce and operate the streaming process to reduce ambulance offloading delays.
  Stated by the Princess Alexandra Hospital NHS TrustStated completed
8. Action
  Assign a nurse and doctor responsibility for patients throughout the ambulance arrival and handover process.
  Stated by the Princess Alexandra Hospital NHS TrustStated completed
9. Action
  Operate an escalation process for ambulance queues or handover delays exceeding 30 minutes, prioritising patients requiring the most urgent attention.
  Stated by the Princess Alexandra Hospital NHS TrustStated completed
10. Action
  Provide an allocated paramedic to continuously monitor patients in the ambulance queue area and escalate concerns.
  Stated by the Princess Alexandra Hospital NHS TrustStated completed
11. Action
  Continue monitoring whether process improvements reduce emergency ambulance waiting times and positively affect patient care.
  Stated by the Princess Alexandra Hospital NHS TrustStated completed
Respondent positions 1
1. Position
  Existing ambulance-handover monitoring, escalation and capacity-management arrangements are considered adequate to address delays.
  Stated by Luton and Dunstable University HospitalExisting arrangements considered sufficient
AI-generated summary

Matthew Luke FAULKNER · 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

Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to hospital.

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 handover to hospital
Wider context from the report
“(4) That there are still significant delays on hand-over to hospital, exacerbating the lack of Ambulances being available to answer emergency calls. ”
Source location
Matthew Luke FAULKNER · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Deploy Patient Safety Intervention Teams to emergency departments experiencing prolonged ambulance handover delays.

Verbatim wording from the response
“The Trust introduced Patient Safety Intervention Teams (PSIT) across the Trust in December 2017 to support our Acute Trust colleagues throughout the winter. These teams were deployed to emergency departments across the region where handover delays were continuing past 45 minutes, where no immediate resolution of the situation is apparent and patients are waiting for an ambulance response in the community. The aim was to minimise patient wait and maximise the availability of ambulances. The teams worked collaboratively with emergency department staff to maintain the safety of patients in the department along with ensuring awareness of those 999 patients who are waiting for a response. This scheme stayed in place until March 2018.”

Source location
2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018
Open published response
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
Collaborate with acute-sector organisations and Clinical Commissioning Groups to resolve hospital handover delays.

Verbatim wording from the response
“I hope this assures you that the Trust is taking considerable action to manage our call demand and utilise the resources available to use in the most efficient way. We are working to improve our capacity by recruiting more staff, supported by additional frontline vehicles. The Trust is also collaborating with the Acute sector and the Clinical Commissioning Groups to resolve the hospital handover delays. Most importantly, we are continuing to educate the public around the appropriate use of the 999 service and looking at innovative ways to support patients with complex needs (mental health street triage teams) or to those who call frequently due to falls.”

Source location
2018-0097-Response-by-East-of-England-Ambulance-Service
Page 2 · response
Published 17 June 2018
Open published response
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
Reconfigure ambulance handover using lean principles to remove non-essential tasks and reduce handover times.

Verbatim wording from the response
“In January 2017 we identified ambulance handover times as a key challenge within our performance targets and in order to address this in March 2017 we sought external expertise to reconfigure the handover process, our aim being to reduce handover times to meet the national standard of 100% within 15 min of arrival, thus releasing ambulance crews in a timelier manner.”

Source location
2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 17 June 2018
Open published response
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
Conduct a June 2018 focus week using the previous improvement methods to restore ambulance handover performance.

Verbatim wording from the response
“We are conducting a focus week in June 2018, mirroring the methods we used to improve the situation last year, in order to bring performance back to the same levels as in April 2017. Having achieved the improvements required, the performance will be monitored on a weekly basis and focus weeks conducted if performance slips.”

Source location
2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 2 · response
Published 17 June 2018
Open published response
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
Monitor ambulance handover performance weekly after implementing the improvements.

Verbatim wording from the response
“We are conducting a focus week in June 2018, mirroring the methods we used to improve the situation last year, in order to bring performance back to the same levels as in April 2017. Having achieved the improvements required, the performance will be monitored on a weekly basis and focus weeks conducted if performance slips.”

Source location
2018-0097-Response-by-East-North-Hertfordshire-NHS-Trust
Page 2 · response
Published 17 June 2018
Open published response
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
Maintain contingency capacity by operating an additional ward and surgical outlier bays to mitigate emergency-department overcrowding and ambulance offload delays.

Verbatim wording from the response
“On 30th May 2017, between 17:00 and 22:00 hours, 19 ambulances were delayed at the Luton and Dunstable Hospital. This consisted of 11 ambulances under 30 mins and 8 ambulances under 60 mins, amounting to 368 minutes in total. As it was the Tuesday post Bank Holiday, ED attendances were expected to be high and indeed 326 patients attended across the 24 hour period, higher than the rolling 30 day average of 296. 88 patients arrived by ambulance which is within normal daily expectations. The bed reports from that day indicates high numbers of patients in the department - at 4pm there were 67 patients in ED and 8pm, 58 patients, which would have caused some overcrowding within the department. Similarly due to the Bank holiday weekend, discharges were reduced compared with normal; the Trust already had taken steps to mitigate this by using one contingency ward of”

Source location
2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 17 June 2018
Open published response
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
Transfer existing emergency-department patients into hospital and assessment beds to prioritise cubicle space for arriving ambulance patients.

Verbatim wording from the response
“It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.”

Source location
2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018
Open published response
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
Open further contingency areas as necessary to proactively create emergency-department capacity and reduce ambulance offload delays.

Verbatim wording from the response
“It is the Trust’s firm belief that it is not safe practice to cohort ambulance patients as these are often the most vulnerable patients in ED having not yet been assessed. Therefore there are a number of other steps taken to assess existing patients and their need for a trolley whilst flexing both capacity within and nearby the department by using it in a different way as well as cohorting stable patients awaiting inpatient beds and boarding patients on inpatient wards. Therefore, at the L&D we prioritise cubicle space for new patients coming in from ambulances, and will transfer existing patients into hospital and assessment beds to accommodate this. We will open further contingency areas as necessary in order to proactively create space rather than react to deficiencies in it.”

Source location
2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018
Open published response
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
Board patients on wards by transferring them before beds become available, temporarily increasing ward capacity.

Verbatim wording from the response
“We will transfer patients to wards where beds will shortly become available even if the space has not yet become”

Source location
2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018
Open published response
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 and operate the streaming process to reduce ambulance offloading delays.

Verbatim wording from the response
“The Trust are committed to ensuring that delays in offloading patients from ambulances are both minimised and escalated in a timely manner. I can assure you that the Medicine Health Care Group have introduced a number of process to prevent delays, these include”

Source location
2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018
Open published response
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
Assign a nurse and doctor responsibility for patients throughout the ambulance arrival and handover process.

Verbatim wording from the response
“• Improvements to Ambulance handover”

Source location
2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 1 · response
Published 17 June 2018
Open published response
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
Operate an escalation process for ambulance queues or handover delays exceeding 30 minutes, prioritising patients requiring the most urgent attention.

Verbatim wording from the response
“Whilst every effort is made to ensure that patients receive their initial assessment within 15 minutes, there are at times of peak demand, or when a number of ambulances arrive at the same time, patients who may have to wait in the designated ambulance queue area which is integral to the ED. There is a clear escalation process which staff will follow should there be an issue with queuing ambulances or a delay in ambulance handover of greater than 30 minutes. Our staff will initiate the ambulance handover escalation process and the priority will be given to the patient who requires the most urgent attention. In addition between the hours of 07.30 and 02.30 this area is further supported by an allocated Paramedic whose role is to continuously monitor the patients in this area and escalate any concerns.”

Source location
2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018
Open published response
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 an allocated paramedic to continuously monitor patients in the ambulance queue area and escalate concerns.

Verbatim wording from the response
“Whilst every effort is made to ensure that patients receive their initial assessment within 15 minutes, there are at times of peak demand, or when a number of ambulances arrive at the same time, patients who may have to wait in the designated ambulance queue area which is integral to the ED. There is a clear escalation process which staff will follow should there be an issue with queuing ambulances or a delay in ambulance handover of greater than 30 minutes. Our staff will initiate the ambulance handover escalation process and the priority will be given to the patient who requires the most urgent attention. In addition between the hours of 07.30 and 02.30 this area is further supported by an allocated Paramedic whose role is to continuously monitor the patients in this area and escalate any concerns.”

Source location
2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018
Open published response
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
Continue monitoring whether process improvements reduce emergency ambulance waiting times and positively affect patient care.

Verbatim wording from the response
“The Trust continues to work at improving the care provided to our patients and will continue to monitor that the improvements in our processes have made a positive impact and will continue to reduce the waiting times of emergency ambulances delivering patients.”

Source location
2018-0097-Response-by-Princess-Alexandra-Hospital-NHS-Trust
Page 2 · response
Published 17 June 2018
Open published response
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
Existing ambulance-handover monitoring, escalation and capacity-management arrangements are considered adequate to address delays.

Verbatim wording from the response
“Generally the L&D’s performance regarding ambulance handovers is considered to be very reasonable. We have long adopted this metric as one of our triggers for patient flow escalation, which is monitored carefully throughout a 24 hour period. We always act upon handover delays if it becomes apparent that flow has reduced, and this is contained within our four times daily bed report. The escalation process involves input from an executive director and one of the medical directors. Whilst there is always room for improvement, the Weekly Sitrep ending 4th June 2017 shows that we had no ambulances waiting over 60 mins through the whole week. Attached to this letter is the East of England Ambulance service data for the period in question, showing the position of the L&D and all other trusts served by EEAST.”

Source location
2018-0097-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 17 June 2018
Open published response
17 May2017
North Wales (East and Central)
Concerns raised1
1. Delays in emergency department patient handover
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement escalation protocols and joint action plans for delayed ambulance handovers.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
2. Action
  Provide hospital liaison officers or duty operational managers when ambulance handovers are delayed.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
3. Action
  Use paramedic guidance to identify suitable patients for transfer to ED waiting rooms rather than remaining in ambulances.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
1. Action
  Explore a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd for rapid handover and assessment.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
2. Action
  Expand Ysbyty Glan Clwyd ED assessment capacity through additional spaces, observation beds and daytime GP facilities.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
AI-generated summary

Lilly Baxandall · 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

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

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 emergency department patient handover
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Source location
Lilly Baxandall · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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
Implement escalation protocols and joint action plans for delayed ambulance handovers.

Verbatim wording from the response
“BCUHB has developed an escalation protocol to ensure a consistent approach to the safe management of patients whose handover is delayed. This is to support the procedure to enable the immediate release of delayed ambulances to enable WAST to respond to life threatening or clinically urgent 999 calls in the community (the immediate release system).”

Source location
2017-0160-Response-by-University-Health-Board
Page 6 · response
Published 17 August 2017
Open published response
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 hospital liaison officers or duty operational managers when ambulance handovers are delayed.

Verbatim wording from the response
“With WAST, BCUHB has also developed a Local Escalation Action Plan (LEAP) which clearly outlines the escalation processes for WAST and BCUHB staff to apply to enable ambulance crews to hand over patients to ED with minimum delay. As part of the ‘LEAP’ protocol, WAST provides a Hospital Ambulance Liaison Officer (HALO) or a Duty Operational Manager (DOM) at hospitals when ambulances are delayed. These are usually WAST Clinical Team Leaders whose role is to supervise crews experiencing handover delays and liaise directly with ED.”

Source location
2017-0160-Response-by-University-Health-Board
Page 6 · response
Published 17 August 2017
Open published response
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 paramedic guidance to identify suitable patients for transfer to ED waiting rooms rather than remaining in ambulances.

Verbatim wording from the response
“The WAST Clinical Contact Centre (CCC) uses a demand management plan to ensure good communications with hospital sites about WAST community activity and demand, particularly during times of handover delays. Delays are escalated to a WAST senior manager who liaises with senior BCUHB officers to agree how resources can be safely released to respond to WAST community activity. WAST and BCUHB have together developed guidance for paramedics to identify patients well enough to be placed in the ED waiting room, rather than wait on an emergency ambulance.”

Source location
2017-0160-Response-by-University-Health-Board
Page 6 · response
Published 17 August 2017
Open published response
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
Explore a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd for rapid handover and assessment.

Verbatim wording from the response
“At Ysbyty Maelor Wrexham, a holding area in ED is created whenever possible during the day to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical ‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.”

Source location
2017-0160-Response-by-University-Health-Board
Page 6 · response
Published 17 August 2017
Open published response
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
Expand Ysbyty Glan Clwyd ED assessment capacity through additional spaces, observation beds and daytime GP facilities.

Verbatim wording from the response
“• A review of the use of the physical space within ED has created an open ambulatory chair centric area with 4 additional assessment/treatment spaces; the commissioning of 2 additional beds in the observation bedded area of the ED; the use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am - 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
Open published response
27 Apr2017
South Wales Central
Concerns raised1
1. Delays in hospital handover causing unavailability of ambulances
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Develop and submit the Unscheduled Care Plan to improve emergency access and reduce ambulance handover delays.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Provide additional evening site-management staffing and strengthen out-of-hours clinical site-management arrangements to support flow and escalation response.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Conduct regular checks, diagnostics and treatment reviews for patients delayed in ambulances to minimise waiting times.
  Stated by Betsi Cadwaladr University LHBStated completed
1. Action
  Coordinate immediate ambulance offload with WAST and emergency departments so ambulances can be released for potentially life-threatening calls.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Anton Kusz · 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

Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.

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 causing unavailability of ambulances
Wider context from the report
“(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital. The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales. One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation. Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others. ”
Source location
Anton Kusz · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 and submit the Unscheduled Care Plan to improve emergency access and reduce ambulance handover delays.

Verbatim wording from the response
“Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached. The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target.”

Source location
2017-0140-Response-by-University-Health-Board
Page 1 · response
Published 16 August 2017
Open published response
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 additional evening site-management staffing and strengthen out-of-hours clinical site-management arrangements to support flow and escalation response.

Verbatim wording from the response
“7. Operational site management; WMH have employed twilight site managers to support evening bed pressures. All three acute hospitals in the Health Board are moving towards a new out of hours site management clinical rota to support flow and response to escalation. This includes additional night sisters to support core site management. WMH also provide a Senior Manager of the day who works till 8pm to support decompression of acute problems affecting flow.”

Source location
2017-0140-Response-by-University-Health-Board
Page 3 · response
Published 16 August 2017
Open published response
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
Conduct regular checks, diagnostics and treatment reviews for patients delayed in ambulances to minimise waiting times.

Verbatim wording from the response
“15. Regular Review of Patient delayed in Ambulances; to help prevent recurrence of the issues you raised relating to Rebecca Evans a system of regular checks, diagnostics and treatment, has been put in place to ensure patients experience the minimum delay.”

Source location
2017-0140-Response-by-University-Health-Board
Page 4 · response
Published 16 August 2017
Open published response
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
Coordinate immediate ambulance offload with WAST and emergency departments so ambulances can be released for potentially life-threatening calls.

Verbatim wording from the response
“16. Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST) they co-ordinate with emergency department to ensure that ambulances can be released to respond to potentially life threatening calls through immediate offload into any available in ED.”

Source location
2017-0140-Response-by-University-Health-Board
Page 4 · response
Published 16 August 2017
Open published response
5 Apr2017
Brighton and Hove
Concerns raised1
1. Failure to complete hospital handovers within the 30-minute national standard
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Introduce an Immediate Handover Policy for ambulance-to-hospital transfers.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
2. Action
  Develop and implement a joint handover standard operating procedure with BSUH, defining responsibilities and escalation processes.
  Stated by South East Coast Ambulance Service NHS Foundation TrustStated completed
3. Action
  Implement the SAFER care bundle to improve patient flow and support earlier discharge.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
1. Action
  Expand Newhaven Downs Community Hospital to create additional discharge capacity.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
2. Action
  Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
3. Action
  Work more closely with South East Coast Ambulance Service to improve ambulance handover processes.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
4. Action
  Implement a joint clinical handover protocol and escalation triggers at 15, 30 and 60 minutes after patient arrival.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
5. Action
  Fund a joint Hospital Ambulance Liaison Officer appointment.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
6. Action
  Commission an observational audit of the ambulance handover process to identify further improvements.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.
  Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Ronald William Bennett · 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

Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his death.

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 complete hospital handovers within the 30-minute national standard
Wider context from the report
“(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day). (2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate. (3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds. (4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death. (5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH. ”
Source location
Ronald William Bennett · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 an Immediate Handover Policy for ambulance-to-hospital transfers.

Verbatim wording from the response
“In recent years, the delays at hospitals for ambulance crews has continually increased, to the point where they are impacting on the Trust’s ability to respond to emergency calls in the community. During 2015, in response to this ever growing problem, we introduced an Immediate Handover Policy. However, due to the challenges at the Royal Sussex County Hospital this was difficult to implement. A special Handover Workshop was facilitated last year in Brighton by Professor Matthew Cooke who had previously been National Clinical Director for Emergency & Urgent Care for the NHS. This was organised by Emergency Care Improvement Programme to seek solutions as the delays at Brighton & Sussex University Hospitals NHS Trust had been rising.”

Source location
2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 28 July 2017
Open published response
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 and implement a joint handover standard operating procedure with BSUH, defining responsibilities and escalation processes.

Verbatim wording from the response
“In March 2017, a new joint Standard Operating Procedure was developed in partnership with BSUH providing more clarity around the process and responsibilities, including how and when to escalate. Since its implementation, there has been a marked improvement in overall performance in handover delays, although it is still the case that many hours continue to be lost.”

Source location
2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 28 July 2017
Open published response
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
Implement the SAFER care bundle to improve patient flow and support earlier discharge.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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
Expand Newhaven Downs Community Hospital to create additional discharge capacity.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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
Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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 more closely with South East Coast Ambulance Service to improve ambulance handover processes.

Verbatim wording from the response
“Since January 2017, there have been significant efforts to work more closely with South East Coast Ambulance Service NHS Foundation Trust (SECAMB) and this has been reflected in improved ambulance handover performance. In March 2017 the ambulance handover performance was the best for two years.”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 28 July 2017
Open published response
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
Implement a joint clinical handover protocol and escalation triggers at 15, 30 and 60 minutes after patient arrival.

Verbatim wording from the response
“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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
Fund a joint Hospital Ambulance Liaison Officer appointment.

Verbatim wording from the response
“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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
Commission an observational audit of the ambulance handover process to identify further improvements.

Verbatim wording from the response
“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
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
Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.

Verbatim wording from the response
“Although I cannot give you assurance that this complex and multi-factorial problem is fixed, I am confident that the matter is now being given sufficient priority by our acute, community and primary care partners. Its impact on our services is significant, and we are doing all we reasonably can to ensure improvement is sustained.”

Source location
2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
14 Mar2017
North Wales (East and Central)
Concerns raised2
1. Delays in handover of patients at an Emergency Department
2. Unavailability of ambulance resources for allocation to other calls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Operate regular ambulance-patient checks, diagnostics and treatment reviews to minimise delays.
  Stated by Betsi Cadwaladr University LHBStated completed
1. Action
  Coordinate immediate emergency-department offload with WAST to release ambulances for potentially life-threatening calls.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Engage ambulance locality leads and implement a Minor Injuries Unit procedure to redirect suitable cases from emergency ambulance pathways.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Rebecca Anne 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

Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and ambulance availability.

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 handover of patients at an Emergency Department
Wider context from the report
“2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”
Source location
Rebecca Anne Evans · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of ambulance resources for allocation to other calls
Wider context from the report
“2. That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls. Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths. ”
Source location
Rebecca Anne Evans · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.

Verbatim wording from the response
“Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached. The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target.”

Source location
2017-0077-Response-by-University-Health-Board
Page 1 · response
Published 24 March 2017
Open published response
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 predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.

Verbatim wording from the response
“The use of information within Unscheduled Care decision making There is extensive use of predictive tools and modeling within our overall approach to Unscheduled Care. The overall capacity and demand model developed by the planning section has informed the scale of improvement required to achieve a bed occupancy level of 85%. The metrics within the overall plan are calibrated at a level which has been calculated to enable the 4 hour target to be achieved and improve ambulance handover.”

Source location
2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017
Open published response
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
Operate regular ambulance-patient checks, diagnostics and treatment reviews to minimise delays.

Verbatim wording from the response
“15. Regular Review of Patient delayed in Ambulances; to help prevent recurrence of the issues you raised relating to Rebecca Evans a system of regular checks, diagnostics and treatment, has been put in place to ensure patients experience the minimum delay.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response
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
Coordinate immediate emergency-department offload with WAST to release ambulances for potentially life-threatening calls.

Verbatim wording from the response
“16. Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST) they co-ordinate with emergency department to ensure that ambulances can be released to respond to potentially life threatening calls through immediate offload into any available in ED.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response
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
Engage ambulance locality leads and implement a Minor Injuries Unit procedure to redirect suitable cases from emergency ambulance pathways.

Verbatim wording from the response
“4. Emergency Departments and WAST; WAST locality Leads are engaged on both sites supporting non-conveyance options for EMS activity. This includes the formal Minor Injuries Units Stand Operating Procedure to redirect suitable clinical cases to MIUs.”

Source location
2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide timely ambulance handover and admission

Concerns raised1

Delays in hospital patient handover causing prolonged ambulance unavailability

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Delays in handover of patients at emergency departments

Concerns raised1

Excessive delays at hospitals

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10

Concerns raised1

Unrealistic target turnaround time for ambulances at A&E

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Delays in handover to hospital

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.14

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 5

Respondent positions 1

Actions described in response 10

Actions described in response 2

Respondent positions 1

Actions described in response 14

Respondent positions 1