Recurring concern

Inadequate system planning for ambulance-delay pressures

First to latest report 24 Oct 2022 — 13 Jun 2025

Reports that mention this concern: 2
Times this concern has been raised: 4
Stated actions linked to this concern: 6

What this concern includes

Includes failures of cross-system planning, leadership response, demand-pressure planning, winter-pressure planning and longer-term solution development when explicitly connected to ambulance attendance or hospital handover delays and their patient-safety consequences.

What is not included

Excludes the ambulance delays, handover delays or capacity shortfalls themselves when no separate planning or system-leadership deficiency is identified.
Excludes generic workforce, funding or service-capacity deficiencies unless the report explicitly identifies inadequate coordinated planning or leadership in response to ambulance-delay pressures.
Excludes operational ambulance dispatch, call handling and hospital handover-process failures that do not concern system-level planning or leadership response.
Excludes generic organisational planning concerns unrelated to ambulance-delay pressures.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1

Welsh Ambulance Services NHS Trust1

Welsh Government1

Reports and published responses 2 reports

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

13 Jun2025
South Wales Central
Concerns raised3
1. Failure to align ambulance rostering assumptions with hospital handover performance
2. Inadequate health and social care system leadership response to ambulance handover pressures
3. Insufficient escalation of ambulance handover delays across health boards
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Welsh Government
Stated actions 4
1. Welsh Government
  Establish a National Handover-45 Taskforce to support system-wide ambulance handover improvements.
2. Welsh Government
  Run 30-, 60- and 90-day rapid improvement events with health-board and operational leaders.
3. Welsh Government
  Seek urgent assurance from each health board on actions supporting handover-guidance compliance and reduced delays.
1. Welsh Government
  Follow up health-board progress through Integrated Quality Planning and Delivery meetings.
Respondent positions 3
1. Welsh Government
  Welsh Ministers set strategic expectations but do not deliver health services; health boards and NHS trusts deliver services within the national policy framework.
  Redirects responsibility
1. Welsh Government
  WAST is responsible for managing and delivering emergency ambulance services, while the JCC plans, secures and commissions them.
  Redirects responsibility
2. Welsh Government
  Health boards are responsible for ensuring ambulance handovers occur reliably, in clinical priority order and within 15 minutes.
  Redirects responsibility
AI-generated summary

Valerie HILL · 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

Valerie HILL died on 11 March 2022 at Royal Glamorgan Hospital after a fall at Ty Bargoed Care Home led to a periprosthetic femur fracture; pneumonia, COPD and frailty of old age were also recorded. She waited on the floor for over 14 hours for an ambulance, and concerns were raised about inadequate care-home risk assessments, prolonged ambulance handover times, patient-flow systems and continuing system-wide delays in access to emergency care.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to align ambulance rostering assumptions with hospital handover performance
Wider context from the report
“(2) Despite some relaxation in the guidelines set by the Welsh Ministers in relation to ambulance handover delays/timings in 2024, WAST continues to adopt the 15 minute handover expectation/assumption for their rostering. Yet I received evidence that hospitals across Wales are only delivering this expectation around 10-20% of the time. My concern is that this disconnect is having a significant effect upon how the system for conveying acutely ill patients in the community to hospital is operating and changes are indicated to address this system dysfunctionality. ”
Source location
Valerie HILL · Prevention of Future Deaths report
Page 2 · 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
Inadequate health and social care system leadership response to ambulance handover pressures
Wider context from the report
“(3) On 17.2.22 ████████ Chief Executive of NHS Wales wrote to you as then Minister for Health and Social Services & in relation to the then acute concerns she had over delayed ambulance handovers indicated as follows:- “A health and social care system leadership response is required to current operational pressures on a par to the Covid-19 response” ████████ in his oral evidence confirmed that the response had not been on a par with the Covid-19 response My concern is that the prevalence and extent of such delays has become beyond intolerable and is leading to many acutely unwell patients in the community waiting for such prolonged periods for emergency care, dying directly & indirectly as a consequence. The balance of risk in the system appears to be borne disproportionately by the patients in that category & consideration ought to be given to redressing the same. ”
Source location
Valerie HILL · 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
Insufficient escalation of ambulance handover delays across health boards
Wider context from the report
“(4) In your response to my Prevention of Future Death Report in relation to Lynda Blackmore (PFD and your response annexed) you indicated inter alia:- “For the past two iterations of the framework, I have been explicitly clear of my expectation that Health Boards prioritise plans to improve timeliness of ambulance patient handover to free up ambulance clinicians to respond to patients in the community…I have also set a priority for improvement of patient flow.” My concern is that the same has not led to any discernible improvement in ambulance handover delays & that consideration might be given for a review of the level of escalation that not only applies on this issue to CTMUHB but also those Health Boards across Wales. I was repeatedly referenced at the Inquest by CTMUHB that their performance in many areas relating to ambulance handover times was not “the worst in Wales”. ”
Source location
Valerie HILL · 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
Establish a National Handover-45 Taskforce to support system-wide ambulance handover improvements.

Verbatim wording from the response
“The independent Getting it Right First Time (GIRFT) and Ministerial Advisory Group on NHS Performance and Productivity report also underscored the need for change. The Cabinet Secretary for Health and Social Care has announced a National Handover-45 Taskforce to support health boards and WAST to deliver system-wide improvements to improve ambulance handover.”

Source location
Response from The First Minister for Wales
Page 3 · response
Published 30 June 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
Run 30-, 60- and 90-day rapid improvement events with health-board and operational leaders.

Verbatim wording from the response
“The taskforce will support health boards and WAST through a series of rapid improvement events over a 30, 60 and 90-day period. These will bring together senior clinical and operational leaders at a health board level with a focus on high-impact pathways, emergency department processes, improving patient flow and encouraging clinical ownership of actions.”

Source location
Response from The First Minister for Wales
Page 3 · response
Published 30 June 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
Seek urgent assurance from each health board on actions supporting handover-guidance compliance and reduced delays.

Verbatim wording from the response
“A review of health board compliance was commissioned in quarter four of 2024-25 and completed in March 2025 by NHS Performance and Improvement. A report containing learning and key themes for health boards to consider was shared by Welsh Government on 18 June 2025. A copy is attached at annex A.”

Source location
Response from The First Minister for Wales
Page 2 · response
Published 30 June 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
Follow up health-board progress through Integrated Quality Planning and Delivery meetings.

Verbatim wording from the response
“Welsh Government officials have sought urgent assurance from each health board about how they will deliver specific actions against the eight aspects from the report to support compliance with the handover guidance and work towards delivery of no delays in excess of 45 minutes by quarter three of 2025-26. Progress will be followed up by officials and NHS Performance and Improvement at Integrated Quality Planning and Delivery meetings with health boards.”

Source location
Response from The First Minister for Wales
Page 2 · response
Published 30 June 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
Welsh Ministers set strategic expectations but do not deliver health services; health boards and NHS trusts deliver services within the national policy framework.

Verbatim wording from the response
“Welsh Ministers set the strategic expectations for health and care services and hold health bodies accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.”

Source location
Response from The First Minister for Wales
Page 1 · response
Published 30 June 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
WAST is responsible for managing and delivering emergency ambulance services, while the JCC plans, secures and commissions them.

Verbatim wording from the response
“The Welsh Ambulance Services National Health Service Trust (Establishment) Order 1998 established the Welsh Ambulance Services University National Health Service Trust (WAST). ████████”

Source location
Response from The First Minister for Wales
Page 1 · response
Published 30 June 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
Health boards are responsible for ensuring ambulance handovers occur reliably, in clinical priority order and within 15 minutes.

Verbatim wording from the response
“The Welsh Government’s clear expectation is that when someone is conveyed to hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.”

Source location
Response from The First Minister for Wales
Page 2 · response
Published 30 June 2025
Open published response
24 Oct2022
North West Wales
Concerns raised1
1. Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Betsi Cadwaladr University LHB
Welsh Ambulance Services NHS Trust
Stated actions 2
1. Betsi Cadwaladr University LHB
  Share the local Ysbyty Gwynedd ambulance handover plan and related emergency department and hospital protocols across Health Board sites for local adoption.
2. Welsh Ambulance Services NHS Trust
  Maintain the Handover Improvement Plan with BCU Health Board and NCCU, using integrated commissioning action plans and fortnightly meetings to improve system flow and ambulance availability.
AI-generated summary

Glenys Roberts · 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

Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability
Wider context from the report
“3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow ”
Source location
Glenys Roberts · 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
Share the local Ysbyty Gwynedd ambulance handover plan and related emergency department and hospital protocols across Health Board sites for local adoption.

Verbatim wording from the response
“The local Ysbyty Gwynedd handover plan has been shared across sites within the Health Board for local adoption, along with ED full protocols and hospital full protocols. These are aligned with the national Operational Pressures Escalation Levels (OPEL) with clear triggers to support de-escalation and reducing delays.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 25 October 2022
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain the Handover Improvement Plan with BCU Health Board and NCCU, using integrated commissioning action plans and fortnightly meetings to improve system flow and ambulance availability.

Verbatim wording from the response
“The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU. Going forward these meetings will be the host for integrated commissioning action plans, part of the refreshed Emergency Medical Services Commissioning Framework approved by Emergency Ambulance Services Committee.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 25 October 2022
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised3

Failure to align ambulance rostering assumptions with hospital handover performance

Inadequate health and social care system leadership response to ambulance handover pressures

Insufficient escalation of ambulance handover delays across health boards

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability

Linked responses

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

Stated actions 4

Respondent positions 3

Stated actions 2