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

Distinct published reports

Individual concerns
86

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
337

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    JAMES FREDERICK SMITH · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance capacity.

    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 ambulance handover at hospitals

    Wider context from the report

    “(2) Significant handover delays at RCHT and other southwest hospitals leading to ambulance resources being tied up with increased response delays and increased mortality risks for patients in the community waiting for emergency ambulances. ”

    Source location

    JAMES FREDERICK SMITH · Prevention of Future Deaths report
    Page 4 · 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

    Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.

    Verbatim wording from the response

    “But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times:”

    Source location

    Response from DHSC
    Page 2 · response
    Published 21 May 2025

    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

    There is no robust evidence directly linking delayed hospital discharges to ambulance handover delays.

    Verbatim wording from the response

    “Whilst high levels of bed occupancy may contribute to ambulance handover delays, hospital discharge delay is one of several factors that contributes to high rates of bed occupancy. We do not have robust evidence linking discharge delays directly to ambulance handover delays. In the NHS Cornwall and the Isles of Scilly Integrated Care Board, in April 2025, the average percentage of adult acute beds occupied by patients remaining despite being medically ready for discharge was 13.5%. For comparison, the average for England at the same period was also 13.5%.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 21 May 2025

    Open published response
  2. Manchester South

    AI-generated summary

    Bernard Lyon · 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

    Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.

    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 ambulance handover to the emergency department

    Wider context from the report

    “5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour. ”

    Source location

    Bernard Lyon · 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

    Monitor urgent and emergency service performance through Trust engagement and available data.

    Verbatim wording from the response

    “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.”

    Source location

    Response from CQC
    Page 6 · response
    Published 16 April 2025

    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

    Inspect urgent and emergency services in trusts performing poorly against national emergency-department targets.

    Verbatim wording from the response

    “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.”

    Source location

    Response from CQC
    Page 6 · response
    Published 16 April 2025

    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

    CQC relies on ongoing monitoring, performance data and targeted inspections for emergency services rather than additional action on emergency-department resourcing.

    Verbatim wording from the response

    “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.”

    Source location

    Response from CQC
    Page 6 · response
    Published 16 April 2025

    Open published response
  3. Cornwall and Isles of Scilly

    AI-generated summary

    Andrew Waters · 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

    Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.

    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 ambulance handover

    Wider context from the report

    “(1) Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances. ”

    Source location

    Andrew Waters · Prevention of Future Deaths report
    Page 4 · 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

    Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.

    Verbatim wording from the response

    “On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 11 April 2025

    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

    Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.

    Verbatim wording from the response

    “Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 11 April 2025

    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

    Set out lessons learned from winter urgent and emergency care pressures.

    Verbatim wording from the response

    “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 11 April 2025

    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

    Put improvements in place to further improve urgent and emergency care services during 2025/26.

    Verbatim wording from the response

    “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 11 April 2025

    Open published response
  4. Cornwall and Isles of Scilly

    AI-generated summary

    Lachlan Charles Campbell · 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

    Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance services.

    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 patient handovers at Royal Cornwall Hospital

    Wider context from the report

    “1) Delay in ambulance response attributable to delays in handover of patients at Royal Cornwall Hospital Mr Campbell had a history of recreational drug misuse with previous non-intentional overdoses. On 31/10/22, he travelled by train from St Austell to St Erth to visit a friend. While with his friend, it is understood he took drugs as he then became unconscious/fell asleep. His friend took him back to the railway station to catch the last train back to St Austall. At approximately 00:15 on 1/11/22, a bus driver saw Lachlan outside the train station. He was on his knees, bent forwards with his head on the ground in what was described as a ‘prayer position.’ A concern for welfare call was made to the emergency services. A police response was delayed, understandably, owing to a higher priority call being received in relation to an incident of potential domestic violence to which the Officers were diverted. The Officers arrived with Lachlan shortly after 01:00. At 01:42, a request was made for an ambulance. This resulted in a Category 2 disposal requiring an attendance within an average of 18 minutes with 90% of incidents to be attended upon within 40 minutes. The Officers left Lachlan at the scene under the understanding that an ambulance would arrive shortly. They had initially wondered if Lachlan was the male involved in the incident of Domestic Violence but once it was recognised he was not and that the suspect was still at large, there was a concern to apprehend the suspect to safeguard the female victim. After a downpour, Officers returned to the scene shortly before 05:00 to find Lachlan in much the same position but now soaked through. They discussed their options and the risk of hypothermia. A chasing call was made to the ambulance service and it was identified there were still 13 Category 2 or higher cases ahead of them. No ETA was provided. The Officers decided to watch Lachlan from their car. At approximately 06:00, his breathing became agonal. The outstanding call was upgraded to Category 1. An ambulance crew arrived on scene at 06:15 just over 4.5 hours after the first call against a target time of 18 minutes. The situation could not be retrieved and resuscitation efforts were abandoned as futile at 07:45. An expert, Professor Lyon, opined that had Lachlan been conveyed to hospital in a timely manner, his death would have been avoided. At inquest, the jury heard from ████████ who works in the patient safety team at South West Ambulance Service Trust. She told us: On 31 October 2022, there were over 730 hours of ambulance time lost to handovers that were over the 15 minute target at RCHT, Derriford Hospital and North Devon District Hospital (NDDH). This is equivalent to approximately 60 DCA ambulance shifts lost to delays (based on a standard 11 hour shift). At RCHT, the average handover time per patient was one hour, 55 minutes and 57 seconds. At Derriford, the average handover was seven hours, five minutes and four seconds. At NDDH, the average handover was two hours, 12 minutes and 27 seconds. These events happened some time ago and I wanted to know if the situation had improved in the meantime. I was advised that in January 2025, the average handover time per patient at Royal Cornwall Hospital was just under 2 hours 15 minutes, in other words, the situation has worsened. This gives rise to an obvious concern and it is in these circumstances that I write to you. May I also take the opportunity to bring to your attention that I have written Preventing Future Death (PFD) reports with the same concerns to two previous Ministers. I am aware some of my colleagues have additionally written with the same concerns. Included in the Reply to my first PFD was a response from ████████, the Chief Executive of the local ICB (to whom this is copied) which set out, most helpfully, a plan of action over the coming years to relieve the current pressures. It is entirely a matter for you how you choose to reply to this report but you may feel an update from Ms Shields would be informative. ”

    Source location

    Lachlan Charles Campbell · 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

    Publish the 2025 NHS mandate prioritising improvements to A&E and ambulance waiting times.

    Verbatim wording from the response

    “On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 4 March 2025

    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

    Set out lessons learned from winter urgent and emergency care pressures.

    Verbatim wording from the response

    “In addition, later in the Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 4 March 2025

    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

    Put improvements in place to further improve urgent and emergency care services during 2025/26.

    Verbatim wording from the response

    “In addition, later in the Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 4 March 2025

    Open published response
  5. Teesside and Hartlepool

    AI-generated summary

    Diana FAIRWEATHER-PURKIS · 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

    Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.

    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 ambulance crew release following hospital attendance

    Wider context from the report

    “2. There are excessive delays in Ambulance crews being released following attendance at hospital, due to delays in patients being handed over to hospital staff. ”

    Source location

    Diana FAIRWEATHER-PURKIS · 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

    Work with commissioners, integrated care boards, acute providers and ambulance services to implement plans improving ambulance handovers.

    Verbatim wording from the response

    “NHS England’s regional teams are continuing to work closely with commissioners, Integrated Care Boards (ICBs), acute NHS providers and ambulance services to implement plans to continue to improve patient handovers. The 2025/26 priorities and operational planning guidance sets out that the NHS should improve ambulance response times and Accident and Emergency (A&E) waiting times compared to 2024/25, and that Category 2 ambulance response times should average no more than 30 minutes across 2025/26. The guidance also sets out some immediate tasks for 2025/26, including to reduce avoidable ambulance dispatches and conveyances and reduce handover delays.”

    Source location

    Response from NHSE
    Page 2 · response
    Published 20 February 2025

    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 multi-agency ambulance-handover improvement and transformation work across the integrated care system.

    Verbatim wording from the response

    “Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).”

    Source location

    Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
    Page 2 · response
    Published 20 February 2025

    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

    Agree revised and standardised policies and procedures for ambulance handover processes, including immediate release, cohorting, diversions and deflections.

    Verbatim wording from the response

    “Ambulance handover delays are a priority area of focus for the ICB, NEAS, and acute provider Foundation Trusts across NENC Integrated Care System (ICS). The multi-agency NENC Strategic Urgent & Emergency Care Network and Local A&E Delivery Boards provide leadership and oversight of a range of transformation initiatives that are being taken to improve patient handover times. There has been a significant programme of work taking place in the second half of 2024/25 to bring together colleagues from across the system (ICS, FT, ambulance trust) to look at ambulance handover improvement and transformation. This programme was externally facilitated and has led to a number of revised and standardised policies and procedures being agreed for elements of the ambulance handover process (e.g., immediate release, cohorting, diverts and deflections etc.).”

    Source location

    Response from NHS NORTH EAST AND NORTH CUMBRIA INTEGRATED CARE BOARD
    Page 2 · response
    Published 20 February 2025

    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

    Publish NHS planning guidance requiring action to improve Category 2 ambulance response times and reduce avoidable dispatches, conveyances and handover delays.

    Verbatim wording from the response

    “On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 20 February 2025

    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

    Publish lessons learned from winter urgent and emergency care pressures.

    Verbatim wording from the response

    “In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 20 February 2025

    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

    Put in place improvements to urgent and emergency care services ahead of the next winter.

    Verbatim wording from the response

    “In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 20 February 2025

    Open published response
  6. Liverpool and the Wirral

    AI-generated summary

    Nicola Emma OWENS · 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

    Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.

    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 of ambulance patients

    Wider context from the report

    “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients. ”

    Source location

    Nicola Emma OWENS · 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

    Publish the 2025 NHS mandate prioritising improvements to A&E and ambulance waiting times.

    Verbatim wording from the response

    “On 30 January 2025, the Government published ‘Road to recovery: the government’s 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that accompanied the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 January 2025

    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

    Publish 2025–26 NHS planning guidance with a target for average Category 2 ambulance responses and actions to reduce dispatches, conveyances and handover delays.

    Verbatim wording from the response

    “On 30 January 2025, the Government published ‘Road to recovery: the government’s 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that accompanied the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 January 2025

    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 towards 15-minute hospital handovers and implement joint arrangements preventing handovers from exceeding 45 minutes.

    Verbatim wording from the response

    “• working towards delivering hospital handovers within 15 minutes, and implementing joint working arrangements that ensure that no handover takes longer than 45 minutes,”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 January 2025

    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 NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.

    Verbatim wording from the response

    “Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 January 2025

    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

    Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.

    Verbatim wording from the response

    “We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 January 2025

    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 plans to improve ambulance handovers, response times and urgent and emergency care flow.

    Verbatim wording from the response

    “NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 31 January 2025

    Open published response
  7. Somerset

    AI-generated summary

    Graham Whiteley · 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

    Graham Whiteley, who had Alzheimer’s disease, a history of seizures and falls, and lived in a care home, walked out when doors were left unlocked and was found having fallen by the roadside with head injuries. He was conveyed to hospital by police after a substantial ambulance delay, developed pneumonia, and died in hospital on 18 June 2024. The principal concerns were delays in ambulance allocation linked to handover delays at acute hospitals, with the report stating that these delays were continuing.

    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 handing over ambulance patients to acute hospitals

    Wider context from the report

    “c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary). d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers. This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays. e) An ambulance was allocated to Mr Whitely at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr Whiteley’s ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call. f) In the event, Avon and Somerset Police conveyed Mr Whiteley to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down. g) The evidence given by the ambulance Trust at the inquest was that the delays in allocating ambulances caused by the delays in handing over to acute hospitals is continuing. ”

    Source location

    Graham Whiteley · 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

    Implement and update the handover-delay standard operating procedure, including escalation levels, locally agreed triggers and immediate handover arrangements.

    Verbatim wording from the response

    “To address handover delays, a Standard Operating Procedure (SOP) was introduced in late 2021. This has since been reviewed and updated, with a reassessment against locally agreed standards conducted in December 2023 and January 2024. The SOP facilitates the effective management of delays by employing four handover escalation levels. Local teams have collaborated with each hospital to determine the specific actions to be taken at each level. The triggers for escalation have also been locally established, enabling a more responsive and tailored approach. Additionally, the approach includes a designated area for immediate patient handover in situations where the Trust is unable to respond to a pending local Category 1 call within a reasonable timeframe.”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

    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 hospitals and system partners through operational meetings, regional task groups and senior county-level meetings to reduce handover delays.

    Verbatim wording from the response

    “SWAST remains committed to collaborating with hospitals to address this issue. In many instances, local operations teams hold daily meetings with their respective Emergency Departments. Resolving delays has been identified as a key priority by the regional NHS England (NHSE) team, and SWAST actively participated in the NHSE Ambulance Handovers task and finish group during the summer of 2024. Additionally, in 2024, a new tier of senior county-level meetings was established, bringing together hospitals, commissioners, NHSE, and SWAST. These meetings have provided SWAST with valuable opportunities to engage in Integrated Care System (ICS) discussions aimed at reducing delays.”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

    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 Ambulance Liaison Officer support at acute hospitals when required to improve patient flow.

    Verbatim wording from the response

    “Building on the aforementioned efforts, several initiatives are being implemented locally and across the South West by SWAST. These include:”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

    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 Somerset Timely Handover Process to initiate rapid handover when transfer has not occurred within 90 minutes of arrival.

    Verbatim wording from the response

    “We have also collaborated with the Somerset system to implement the ‘Timely Handover Process,’ designed to initiate a rapid handover if it has not been completed within 90 minutes of arrival. This process was introduced in the area in November 2024 and following a challenging Christmas period we are now seeing early improvements in handover efficiency.”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 2 · response
    Published 4 February 2025

    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

    Handover delays cannot be resolved by SWAST alone and require action by hospitals and wider system partners.

    Verbatim wording from the response

    “Handover delays at hospital trusts have the biggest impact on SWAST’s ability to respond to patients. This articulated on the SWAST corporate risk register, where a risk related to system activity and flow sits at the highest level, with a risk score of 25. The challenge with impacts of handover delays is that SWAST alone cannot solve it. In August 2023, the Health Services Safety Investigation Body (HSSIB) published a final report ‘Harm caused by delays in transferring patients to the right place of care’. This report strengthens the findings of the SWAST system PSII report that was produced in July 2022, with a review and addendum added in December 2023. It is recognised that a patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment.”

    Source location

    Response from South Western Ambulance Service NHS Foundation Trust
    Page 1 · response
    Published 4 February 2025

    Open published response
  8. Berkshire

    AI-generated summary

    Andrew Michael Lewis · 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

    Andrew Michael Lewis died at home on 7 May 2024 after calling 111 with weakness in his legs and an earlier fall. An ambulance arrived about 10 hours after his first call, although the call had been categorised as requiring attendance within two hours; the report states there was simply no ambulance available to send earlier. The inquest recorded the cause of death as acute on chronic gastrointestinal haemorrhage, bleeding oesophageal varices, alcoholic liver cirrhosis, and low volume subdural haemorrhage, with the conclusion of an alcohol-related death contributed to by head injury.

    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

    Persistent ambulance queuing at hospitals

    Wider context from the report

    “• I have also been provided with data regarding the number of hours that ambulances have spent queuing at hospitals in the last 3 months (September to November 2024). This amounts to 23,253 hours. This is an average of 255.5 hours across the service every single day. ”

    Source location

    Andrew Michael Lewis · Prevention of Future Deaths report
    Page 3 · 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

    Increase ambulance capacity by growing the workforce, improving hospital flow, reducing handover delays, speeding discharges, and expanding community services.

    Verbatim wording from the response

    “NHS England recognises the significant pressures on all NHS services, including ambulances, and has been prioritising improvements to Category 2 response times and urgent and emergency care services. NHS England has also recognised the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow and ambulance response times. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 27 December 2024

    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 local authorities to improve timely patient discharge and monitor performance using discharge metrics.

    Verbatim wording from the response

    “NHS England recognises the significant pressures on all NHS services, including ambulances, and has been prioritising improvements to Category 2 response times and urgent and emergency care services. NHS England has also recognised the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow and ambulance response times. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 27 December 2024

    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 working with trusts and services facing significant front-end handover challenges to reduce ambulance handover delays.

    Verbatim wording from the response

    “Improvements to ambulance response times are also being enabled by addressing excessive handover delays. Rapid handovers are essential to ensure that patients reach definitive care promptly, which includes both those waiting to receive care in the Emergency Department (ED), and those waiting in the community. NHS England continues to work with trusts and services with significant handover challenges at the”

    Source location

    Response from NHS England
    Page 1 · response
    Published 27 December 2024

    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

    Publish the NHS mandate and planning guidance specifying ambulance response-time targets and actions to reduce avoidable dispatches, conveyances and handover delays.

    Verbatim wording from the response

    “On 30 January 2025 the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving the average Category 2 ambulance response times to no more than 30 minutes across 2025-26, and practical actions focused on reducing avoidable ambulance dispatches and conveyances and ambulance handover delays.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 27 December 2024

    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

    Set out lessons learned from winter pressures on urgent and emergency care services.

    Verbatim wording from the response

    “In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 27 December 2024

    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

    Put improvements in urgent and emergency care services in place ahead of the following winter.

    Verbatim wording from the response

    “In addition, by this Spring we will also set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to improve services ahead of next winter.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 27 December 2024

    Open published response
  9. East Riding and Hull

    AI-generated summary

    Colin Wiles · 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

    Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

    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 ambulance patient handover waiting times at Hull Royal Infirmary

    Wider context from the report

    “(3) The waiting times for ambulances to hand over patients at Hull Royal Infirmary were excessive that day leading to 160 hours of lost ambulance time. ”

    Source location

    Colin Wiles · Prevention of Future Deaths report
    Page 3 · 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

    Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary

    Wider context from the report

    “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances. ”

    Source location

    Colin Wiles · Prevention of Future Deaths report
    Page 3 · 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 the phased 045 Handover Plan to reduce ambulance handover times toward a 45-minute target.

    Verbatim wording from the response

    “On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times:”

    Source location

    Response from NHS Humber Health Partnership
    Page 1 · response
    Published 2 December 2024

    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

    Activate the Ambulance Delay Protocol, including site escalation, rapid patient transfers, and prioritisation of suitable patients.

    Verbatim wording from the response

    “1. Ambulance Delay Protocol Activation: The Ambulance Delay Protocol mandates that ambulance patients should be handed over within 15 minutes of arrival, with no patient waiting longer than 60 minutes. If a delay exceeds 45 minutes with no immediate plan to hand over, the protocol is triggered, requiring:”

    Source location

    Response from NHS Humber Health Partnership
    Page 1 · response
    Published 2 December 2024

    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

    Revise the operating procedure to offload up to eight ambulances hourly and transfer ten patients from the Emergency Department to inpatient wards.

    Verbatim wording from the response

    “3. Proactive Patient Flow Management:”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 Pull for Safety to maintain regular patient flow from the Emergency Department to assessment areas and wards.

    Verbatim wording from the response

    “• Implementing the Pull for Safety process, which establishes a regular patient flow from the ED to assessment areas and wards.”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 escalation areas and reverse boarding protocols to create immediate capacity for arriving patients.

    Verbatim wording from the response

    “• Utilising escalation areas and reverse boarding protocols to create immediate capacity for new arrivals, as detailed in the policy.”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 Temporary Escalation Space and Boarding SOP to manage capacity challenges, patient boarding, and timely Emergency Department handovers.

    Verbatim wording from the response

    “Between March and April 2023, 20–25% of the Trust's bed base (approximately 180 beds, equivalent to six wards) was occupied by NCTR patients on discharge pathways 1–3. This occupancy severely impacted patient flow and the availability of beds for incoming ED patients. In response, the Trust has undertaken a series of strategic measures to alleviate these pressures. In November 2024 the Trust implemented the Temporary Escalation Space (TES) and Boarding SOP, which provides a framework for managing capacity challenges and improving flow.”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 and operate a 54-bed NCTR unit to accommodate patients awaiting discharge and reduce reliance on acute beds.

    Verbatim wording from the response

    “1. Creation of Additional Capacity:”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 updated discharge protocols covering local-authority coordination, family and carer involvement, and care transfer hubs.

    Verbatim wording from the response

    “2. Formal Discharge and Flow Improvements:”

    Source location

    Response from NHS Humber Health Partnership
    Page 2 · response
    Published 2 December 2024

    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 board rounds and huddles to identify discharges early and meet ward discharge targets of 30% by noon and 70% by 17:00.

    Verbatim wording from the response

    “• Boarding Protocols: The SOP outlines structured boarding processes to manage NCTR patients effectively and create capacity in the ED. This includes: - Identifying and moving up to three patients per ward to temporary escalation spaces (TES) or discharge lounges within 30 minutes. - Ensuring timely handovers from ED to inpatient wards to free up ED spaces.”

    Source location

    Response from NHS Humber Health Partnership
    Page 3 · response
    Published 2 December 2024

    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

    Enforce maximum stays of 24 hours in AMU and 12 hours in the Emergency Department to maintain patient flow.

    Verbatim wording from the response

    “3. Operational Measures from the TES and Boarding SOP:”

    Source location

    Response from NHS Humber Health Partnership
    Page 3 · response
    Published 2 December 2024

    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 arrivals and Emergency Department capacity in real time and escalate boarding or discharge issues through clinical and senior leadership.

    Verbatim wording from the response

    “4. Senior Oversight and Escalation:”

    Source location

    Response from NHS Humber Health Partnership
    Page 3 · response
    Published 2 December 2024

    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 working with trusts and services facing significant ambulance handover challenges.

    Verbatim wording from the response

    “the community. NHS England are continuing to work with trusts and services with significant handover challenges at the ‘front end’, alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient flow and allow new patients to be handed over more promptly to EDs.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 2 December 2024

    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

    Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.

    Verbatim wording from the response

    “NHS England will also be prioritising:”

    Source location

    Response from NHS England
    Page 3 · response
    Published 2 December 2024

    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

    Prioritise reducing delays in urgent and emergency care pathways.

    Verbatim wording from the response

    “NHS England will also be prioritising:”

    Source location

    Response from NHS England
    Page 3 · response
    Published 2 December 2024

    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

    Prioritise improving length of stay in NHS-commissioned community beds.

    Verbatim wording from the response

    “NHS England will also be prioritising:”

    Source location

    Response from NHS England
    Page 3 · response
    Published 2 December 2024

    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

    Local and system concerns fall outside NHS England’s national policy and programme remit.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    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

    Local organisations should address the local and system concerns raised in the report.

    Verbatim wording from the response

    “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 2 December 2024

    Open published response
  10. Swansea and Neath Port Talbot

    AI-generated summary

    Peter Parker · 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 Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of ambulances due to prolonged waits to offload patients at hospitals

    Wider context from the report

    “During the course of the inquest the reason given for the significant delay to respond to the call was ambulances waiting at Emergency Departments to hand over patients, meaning that the ambulances are not therefore responding to calls for assistance. The longest wait at the Emergency Department by an ambulance on the evening in question was 11-12 hours, which is the equivalent of a whole 12 hour shift where that ambulance was not responding to calls. The inquest heard evidence that when the MPDS system was introduced in 2015 it was envisaged that an Amber 1 priority call would be responded to in 20 minutes from the time of the call and that a person with a transected radial artery could expect to survive 30-45 minutes. Given that it was not feasible for Peter to transport himself to hospital, and Peter had not contacted his family for their assistance. I am concerned that the response time in this case was beyond the expected survivability of such an injury. The Amber 1 priority rating was by itself not incorrect but was inappropriate in the context of the time taken to respond to such priorities on the evening in question. I am further concerned that the reason for the delay was due to ambulances waiting to offload patients at hospitals, in accordance with the ambulance’s duty of care, and therefore not responding to emergency calls as is their purpose. 1. There was a significant delay in getting an ambulance to Peter which resulted in him dying from his injuries before assistance arrived. The time for survival of such injuries was 30-45 minutes, however the time taken to respond was in excess of 9 hours. Whilst there is no specific target for Amber 1 calls it was envisaged that when the system was introduced such calls would be responded to in 20 minutes. ”

    Source location

    Peter Parker · 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

    Create a broader range of face-to-face response options to support safe treatment at home and avoid unnecessary hospital conveyance.

    Verbatim wording from the response

    “◦ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. ◦ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care”

    Source location

    Response from WELSH AMBULANCE SERVICE NHS TRUST
    Page 3 · response
    Published 22 October 2024

    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 commissioners, health boards and system partners to improve access to local care pathways and develop safe referral options.

    Verbatim wording from the response

    “◦ Choice: A greater range of response options will be created for those patients who need a face-to-face assessment, designed to enable more patients to be treated safely at home and to avoid conveyance to an Emergency Department. ◦ Collaboration: Increased effort will be put into working with commissioners and system partners at national and local level to identify and develop appropriate care”

    Source location

    Response from WELSH AMBULANCE SERVICE NHS TRUST
    Page 3 · response
    Published 22 October 2024

    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

    Action all Red ambulance-release requests and facilitate prompt release of identified emergency resources.

    Verbatim wording from the response

    “Step 1 – WAST will contact ED staff via the “red phone” and direct an immediate release of an ambulance delayed outside the ED when no other appropriate resource is available to respond to a Red or Amber1 patient and/or when the resource has an extended travel time and nearer appropriate resources could attend that patient. The direction made by WAST will share the incident priority, patient age and chief complaint, identify the number of resources that are required to be released and the callsigns of the resources to be released (those that are immediately able to respond to the incident).”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 3 · response
    Published 22 October 2024

    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

    Assess, document and notify site management of decisions to decline Amber1 ambulance-release requests.

    Verbatim wording from the response

    “Step 3 – Should an immediate release direction be declined by the ED staff, WAST will act in accordance with the WAST Resource Deployment SOP and record and escalate the refusal to the Operational Delivery Unit. If a Health Board does decline an immediate release direction, they will be required to provide the reasons for this and the name or identifying detail (e.g., employee number) of the declining staff member.”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 3 · response
    Published 22 October 2024

    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 delays and lost hours daily using established performance measures.

    Verbatim wording from the response

    “The Health Board actively monitors ambulance handover performance against the following two performance measures, on a daily basis:”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 4 · response
    Published 22 October 2024

    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

    Carry out a targeted programme to redesign urgent and emergency care access, services, staffing and infrastructure to reduce patient harm and service failure.

    Verbatim wording from the response

    “The Health Board has commenced a programme of targeted intervention in conjunction with the National Strategy for Right Care, Right Place, First Time: Six Goals for Urgent & Emergency Care, supported by Welsh Government, to address risks associated with urgent and emergency patient pathways, including the ability to release emergency response vehicles, following arrival at Morriston Hospital. The aim of this programme of work is to critically review and redesign across community access, service delivery, staffing models and infrastructure in order to reduce risk of patient harm and service failure.”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 4 · response
    Published 22 October 2024

    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

    Set annual NHS planning expectations and ambulance handover, patient-flow and delayed-discharge improvement priorities, including a 30% reduction aspiration.

    Verbatim wording from the response

    “The Welsh Government communicates its expectations of health boards and NHS Trusts through an annual NHS planning framework and organisations are expected to produce integrated medium-term plans annually that respond to the priorities set in the NHS planning framework.”

    Source location

    Response from Welsh Government
    Page 2 · response
    Published 22 October 2024

    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 delivery of urgent and emergency care priorities through bi-monthly Integrated Quality, Planning and Delivery meetings.

    Verbatim wording from the response

    “Successful delivery of these plans should support improvements across a range of measures, including the reduction of ambulance patient handover delays contributing to improved ambulance responsiveness. Progress in delivering these priorities is monitored through bi-monthly Integrated Quality, Planning and Delivery meetings between Welsh Government officials, representatives of the NHS Executive and health boards.”

    Source location

    Response from Welsh Government
    Page 3 · response
    Published 22 October 2024

    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 publish national ambulance patient handover guidance setting expectations for relevant NHS organisations and clinicians.

    Verbatim wording from the response

    “More recently, the Welsh Government has developed new ambulance patient handover guidance – published on 29 October 2024 which sets out expectations of the NHS Wales Joint Commissioning Committee, ambulance clinicians and health boards to support improved ambulance patient handover. The NHS Executive will undertake audits of organisations’ compliance with the guidance over the remainder of 2024/2025, and we have been clear that health boards must also undertake their own audits of compliance.”

    Source location

    Response from Welsh Government
    Page 3 · response
    Published 22 October 2024

    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 development of a community-based falls response framework to reduce unnecessary ambulance responses and emergency department transfers.

    Verbatim wording from the response

    “Additionally, the Welsh Government commissioned the development of a community based falls response framework which was published by the NHS Executive on 30 October 2024 and a national task group established to enable health boards to deliver. The intention is to better support people who have fallen but are not seriously ill or injured, to safely avoid the need for an ambulance response or transport to emergency departments, thus reducing ambulance patient handover delays and improving experience and outcomes.”

    Source location

    Response from Welsh Government
    Page 3 · response
    Published 22 October 2024

    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

    Launch a 50-day integrated care winter challenge funded by additional Welsh Government funding to accelerate safe alternatives to admission and timely discharge.

    Verbatim wording from the response

    “The Welsh Government has also recently launched a 50-day integrated care winter challenge (‘the challenge’) based on learning from other parts of the UK. The Welsh Government identified ten high-impact and best practice actions for health boards, regional partnership boards and local authorities to deliver between 11 November and 31 December 2024.”

    Source location

    Response from Welsh Government
    Page 3 · response
    Published 22 October 2024

    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

    Review lessons from the winter challenge after its initial 50 days to support sustained implementation of best-practice actions.

    Verbatim wording from the response

    “The Welsh Government are monitoring progress very closely and will review lessons learned following completion of the initial 50 days on 31 December 2024 to support sustained implementation of the best practice actions in 2025 and onwards. The Welsh Government also continues to engage regularly with other UK nations to learn lessons about solutions to the ambulance patient handover issue and will be seeking to transfer learning to improve performance in Wales in 2025.”

    Source location

    Response from Welsh Government
    Page 4 · response
    Published 22 October 2024

    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 engaging with other UK nations and seek to transfer learning to improve ambulance patient handover performance in Wales.

    Verbatim wording from the response

    “The Welsh Government are monitoring progress very closely and will review lessons learned following completion of the initial 50 days on 31 December 2024 to support sustained implementation of the best practice actions in 2025 and onwards. The Welsh Government also continues to engage regularly with other UK nations to learn lessons about solutions to the ambulance patient handover issue and will be seeking to transfer learning to improve performance in Wales in 2025.”

    Source location

    Response from Welsh Government
    Page 4 · response
    Published 22 October 2024

    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

    Emergency department handover delays reduce ambulance capacity and constrain the Trust’s ability to provide timely responses despite internal improvement measures.

    Verbatim wording from the response

    “We hope that this information supports our position that we are doing everything within our sphere of control and influence to deliver more timely, safer care however we are acutely aware of the limitations of our actions within the wider health and care landscape of extreme pressures across Urgent and Emergency Care systems. The number of hours' worth of Trust emergency ambulance production lost per month due to long waits at emergency departments is consistently reaching the 25,000 to 30,000 hours mark. This equates to approximately 20 per cent to 25 per cent of our entire fleet capacity every month as a result of the pressure right across the urgent and emergency care system. This issue remains the highest influencing factor on our ability to provide timely responses, far above and beyond the incremental improvement measures being taken internally by the Trust.”

    Source location

    Response from WELSH AMBULANCE SERVICE NHS TRUST
    Page 4 · response
    Published 22 October 2024

    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 handover delays were solely caused by insufficient hospital capacity, including safe space, clinical support and staffing.

    Verbatim wording from the response

    “The reason for handover delays is solely related to a lack of capacity to bring the conveyed patient into the hospital; both in terms of safe physical space including access to essential clinical support and staffing to take care of the patient. All patient’s waiting on the back of ambulances will have been clinically assessed and all opportunities explored as to how best to deliver a safe, timely, clinical management plan. The Emergency Department at Morriston Hospital routinely functions with additional patients across its template including within the acute resuscitation area, with “Major” patients overflowing into the “Minors” area and “Minors” patients sitting in the “Waiting Room”.”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 3 · response
    Published 22 October 2024

    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

    Amber1 ambulance release requests may be declined where accepting additional patients creates a significant or severe clinical safety risk.

    Verbatim wording from the response

    “I can confirm that all Red release requests are actioned by the Health Board. Amber1 release requests are managed on a case-by-case basis and the Health Board may have to decline requests when there is a significant/severe clinical safety risk to the Emergency”

    Source location

    Response from SWANSEA BAY UNIVERSITY HEALTH BOARD
    Page 3 · response
    Published 22 October 2024

    Open published response
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Data last updated 7 September 2026