Recurring concern

Lack of overarching responsibility for patient safety risks from ambulance delays

First to latest report 22 Sep 2024 — 3 Oct 2024

Reports that mention this concern
2
Times this concern has been raised
4
Stated actions linked to this concern
0

What this concern includes

Includes failures to assign, define or exercise overarching accountability for patient safety risks caused by ambulance delays, including gaps where responsible organisations lack control over the services primarily responsible for delays.

What is not included
  • Excludes generic failures of governance or accountability that are not explicitly tied to patient safety risks from ambulance delays.
  • Excludes operational ambulance-delay causes, response-time failures or service-capacity deficiencies unless the report specifically frames them as an overarching accountability gap for the associated patient-safety risk.
  • Excludes responsibility gaps concerning other transport, referral, discharge or emergency-care processes.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Kevin George Woods · Prevention of Future Deaths report

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

    Report summary

    Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of control over services primarily responsible for ambulance delays

    Wider context from the report

    “4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays. ”

    Source location

    Kevin George Woods · Prevention of Future Deaths report
    Page 4 · 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

    Lack of overarching responsibility for patient safety risks from ambulance delays

    Wider context from the report

    “4) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays. ”

    Source location

    Kevin George Woods · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Cornwall and Isles of Scilly

    AI-generated summary

    DENNIS RICHARD HARRY · 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

    Dennis Richard Harry died at Royal Cornwall Hospital on 10 January 2023 from heart disease and Covid-19 infection following an 18-hour-and-50-minute ambulance delay, including delays in response and hospital handover. The report identified systemic concerns about inadequate social care, community hospital provision and primary healthcare support contributing to delayed discharges, ambulance delays and emergency department crowding. It also identified no single organisation with responsibility for ensuring sufficient social care provision or overseeing patient safety risks from ambulance delays.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of overarching responsibility for patient safety risk from ambulance delays

    Wider context from the report

    “3) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays. ”

    Source location

    DENNIS RICHARD HARRY · Prevention of Future Deaths report
    Page 4 · 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

    Lack of organisational control over services primarily responsible for ambulance delays

    Wider context from the report

    “3) There is an absence of any overarching organisation with responsibility for patient safety risk from ambulance delays. The organisations immediately required to deal with ambulance delays do not have control over the services primarily responsible for the delays. ”

    Source location

    DENNIS RICHARD HARRY · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026