Recurring concern

Delays in ambulance attendance

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First reported 24 Feb 2014•Latest report 23 Mar 2026

Definition

What this concern includes

Includes recurring failures, resource constraints, dispatch problems and other dedicated ambulance-service response failures that result in delayed attendance to patients or emergency calls.

Not included

Excludes delays occurring after ambulance arrival, including hospital handover and crew-release delays.
Excludes delays in other emergency services, such as police, fire and rescue, or specialist clinical on-call attendance.
Excludes generic staffing, capacity or information-sharing deficiencies unless the reports explicitly tie them to delayed ambulance attendance.

Reports: 118
Individual concerns: 129
Date range: 2014–2026
Stated actions: 460

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care53

NHS England25

Welsh Ambulance Services NHS Trust22

Betsi Cadwaladr University LHB9

North East Ambulance Service NHS Foundation Trust8

Association of Ambulance Chief Executives7

East of England Ambulance Service NHS Trust7

East Midlands Ambulance Service NHS Trust6

Welsh Government6

Conwy County Borough Council4

Denbighshire County Council4

Flintshire County Council4

Gwynedd Council4

Isle of Anglesey County Council4

NHS West Yorkshire Integrated Care Board4

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.

10 Jul2023
North West Wales
Concerns raised1
1. Delays in ambulance response and arrival
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Take all possible steps within the Trust’s control to ensure resources are available for Red and Amber calls.
  Stated by The TrustStated in progress
2. Action
  Seek Welsh Government, NHS and local-government support for clinical risk management across urgent and emergency care pathways to release Trust resources.
  Stated by The TrustStated in progress
3. Action
  Maintain and regularly critique and monitor the Clinical Safety Plan and Regional Escalation Action Plan across the organisation.
  Stated by The TrustStated completed
1. Action
  Present and review the Real-time Mitigation Report and Reducing Patient Harm Action Plan at Trust Board meetings.
  Stated by The TrustStated completed
2. Action
  Liaise directly with Health Boards and wider health and social care partners to secure support for timely responses to Red and Amber calls.
  Stated by The TrustStated in progress
Respondent positions 2
1. Position
  No further or new action is proposed in response to the concerns.
  Stated by The TrustNo action considered necessary
1. Position
  Existing plans, monitoring and escalation arrangements are considered sufficient to manage timely responses to Red and Amber calls.
  Stated by The TrustExisting arrangements considered sufficient
AI-generated summary

Mary Elizabeth Jones · Prevention of Future Deaths report

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

Report summary

Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.

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 response and arrival
Wider context from the report
“This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. ”
Source location
Mary Elizabeth Jones · 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
Take all possible steps within the Trust’s control to ensure resources are available for Red and Amber calls.

Verbatim wording from the response
“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
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 Welsh Government, NHS and local-government support for clinical risk management across urgent and emergency care pathways to release Trust resources.

Verbatim wording from the response
“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
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 and regularly critique and monitor the Clinical Safety Plan and Regional Escalation Action Plan across the organisation.

Verbatim wording from the response
“The Trust has evidenced this work through the comprehensive details of all the actions that we have taken to date, and I have also shared with you the measures that are currently in place, such as the Clinical Safety Plan and the Regional Escalation Action Plan. I have not attached copies of these Plans again, as I have previously supplied them.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
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
Present and review the Real-time Mitigation Report and Reducing Patient Harm Action Plan at Trust Board meetings.

Verbatim wording from the response
“I have shared with you copies of the Real-time Mitigation Report and the Reducing Patient Harm Action Plan, both of which were presented to the Public Trust Board on the 27 July 2023. This Report is regularly presented to, and reviewed by, the Trust Board and I hope this offers you assurance that this matter continues to remain a significant risk and a matter of attention to the full Trust Board.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
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
Liaise directly with Health Boards and wider health and social care partners to secure support for timely responses to Red and Amber calls.

Verbatim wording from the response
“To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
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
No further or new action is proposed in response to the concerns.

Verbatim wording from the response
“At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing plans, monitoring and escalation arrangements are considered sufficient to manage timely responses to Red and Amber calls.

Verbatim wording from the response
“To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 18 July 2023
Open published response
6 Jul2023
North Wales (East and Central)
Concerns raised1
1. Delays in ambulance attendance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Emlyn Victor 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

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

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 attendance
Wider context from the report
“Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable. It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community). I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions. ”
Source location
Emlyn Victor Roberts · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Jun2023
North Wales (East and Central)
Concerns raised1
1. Failure to maintain timely ambulance availability and arrival for patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Jean Frickel · 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

Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

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 maintain timely ambulance availability and arrival for patients
Wider context from the report
“There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following:- 1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and 3. Extent of Strategic plan of action / improvement plan to address the above issues. ”
Source location
Jean Frickel · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jun2023
Manchester South
Concerns raised1
1. Failure to provide timely category 2 ambulance responses
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Maintain additional ambulance capacity funded to expand services and improve response times.
  Stated by Department of Health and Social CareStated completed
3. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Maintain the uplift in staffed, permanent hospital bed capacity during 2024/25.
  Stated by Department of Health and Social CareStated completed
2. Action
  Scale up and maintain national virtual ward bed capacity above 10,000 beds.
  Stated by Department of Health and Social CareStated completed
3. Action
  Provide funding to support timely and effective hospital discharge by NHS organisations and local authorities.
  Stated by Department of Health and Social CareStated completed
4. Action
  Continue working with NHS England to reduce ambulance response times.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Joan Mary Corcoran · 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

Joan Mary Corcoran suffered an accidental fall, underwent surgery for a fractured neck of femur, and subsequently developed pneumonia, an infected wound and increasing frailty. After becoming unwell with chest pains, she experienced a 1-hour 5-minute delay for a category 2 ambulance response and died in the ambulance from complications of heart failure while being transported to hospital. The substantive concern was that ambulance response delays were significantly outside target times and reflected wider system pressures, including demand for ambulances and delays at A&E 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
Failure to provide timely category 2 ambulance responses
Wider context from the report
“The inquest heard evidence that under the Department of Health’s Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases. The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes - significantly outside the target time. A response within the target time would have meant that she would not have deteriorated and died in the ambulance. She would have been in a hospital with access to treatment available in such a setting. The evidence before the inquest was that her case was not a one off and delays of this nature had been occurring throughout the day. The mean time for Category 2 response times that day was 1 hour and 22 minutes and the 90th percentile was just over 3 hours. At 17.58 that day there were 142 emergencies waiting in Greater Manchester alone and 430 across the North West. The average response time at that point for Category 2 patients was 2 hours and 33 minutes. The inquest heard that the cause of these significant delays in patients receiving care in a timely manner was multifactorial and included the demand for ambulances across Greater Manchester and the North West and the long ambulance delays at A and E departments due to the demand on A and E services. ”
Source location
Joan Mary Corcoran · 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 delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response
“As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 22 June 2023
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 additional ambulance capacity funded to expand services and improve response times.

Verbatim wording from the response
“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 22 June 2023
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
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 22 June 2023
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 uplift in staffed, permanent hospital bed capacity during 2024/25.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 22 June 2023
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
Scale up and maintain national virtual ward bed capacity above 10,000 beds.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 22 June 2023
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 funding to support timely and effective hospital discharge by NHS organisations and local authorities.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 22 June 2023
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 NHS England to reduce ambulance response times.

Verbatim wording from the response
“However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 22 June 2023
Open published response
20 Jun2023
North Wales (East and Central)
Concerns raised1
1. Delays in ambulances arriving to patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Leonard Charles Harmsworth · 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

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in ambulances arriving to patients
Wider context from the report
“Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff. Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community). I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals. I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. ”
Source location
Leonard Charles Harmsworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 May2023
Suffolk
Concerns raised1
1. Failure to provide timely ambulance responses to Category 2 calls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide £220 million of additional ambulance funding to expand capacity and improve response times.
  Stated by Department of Health and Social CareStated completed
3. Action
  Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStatus unclear
2. Action
  Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.
  Stated by Department of Health and Social CareStated completed
3. Action
  Maintain the 5,000-bed hospital capacity uplift during 2024/25.
  Stated by Department of Health and Social CareStated in progress
4. Action
  Scale up virtual ward capacity to more than 10,000 beds nationally.
  Stated by Department of Health and Social CareStated completed
5. Action
  Make £1.6 billion available over two years to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated completed
6. Action
  Continue working with NHS England and healthcare partners to improve Category 2 ambulance response times.
  Stated by East of England Ambulance Service NHS TrustStated in progress
Respondent positions 2
1. Position
  East of England Ambulance Service NHS Trust is best placed to respond on local actions to improve ambulance response times.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Category 2 response-time performance is not an issue specific to this Trust, as action is required nationally and locally.
  Stated by East of England Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Michael James Francis Bray · 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

Michael James Francis Bray was at home on 9 and 10 October 2021 after drinking alcohol and contacting a crisis helpline while considering hanging himself; he died by hanging between about 1:50 am and 5:53 am on 10 October 2021. The report identified concerns about prolonged delays in responding to Category 2 ambulance calls, including persistently above-target response times, alongside issues concerning inter-agency communication, police and ambulance responses, and welfare checks.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide timely ambulance responses to Category 2 calls
Wider context from the report
“Although it could not be safely said when the deceased died, and therefore it could not safely be said that the delay in the ambulance response probably contributed to the death, the concern is that long delays in ambulance response to Category 2 calls create a risk that other deaths will occur in the future. Bearing in mind the national ambulance target response time for a Category 2 call of an average of 18 minutes, with 90% of calls to be responded to within 40 minutes: The average Category 2 response time for the East of England Ambulance Service NHS Trust (‘EEAST’) in October 2021, the month of this death, was 56 minutes and 2 seconds. The same average time for January 2023, the most recent month for which data was available, was 49 minutes and 3 seconds. Every month since the deceased’s death, EEAST’s Category 2 response time has been above the 90th percentile time of 40 minutes. The average EEAST Category 2 response time for a given month in the period from October 2021 to January 2023 is over 1 hour, with a standard deviation of about 20 minutes. Therefore, EEAST’s Category 2 response time remains persistently and consistently far off target. Although I accept on the evidence that action is being taken, on both local and national levels, to prevent future deaths as a result of this issue, the evidence of the results of such actions to date is that these actions have been demonstrably ineffective and have not resulted in a Category 2 average response time for EEAST that is even close to the target time. The evidence received was that this issue, and the causes for it and the action required, are not just local in nature, but also national. ”
Source location
Michael James Francis Bray · 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 delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response
“I recognise the significant pressure services are facing. That is why we published our Delivery plan for recovering urgent and emergency care services, which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times to 30 minutes on average this year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Provide £220 million of additional ambulance funding to expand capacity and improve response times.

Verbatim wording from the response
“A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.

Verbatim wording from the response
“A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £220 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Maintain the 5,000-bed hospital capacity uplift during 2024/25.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Scale up virtual ward capacity to more than 10,000 beds nationally.

Verbatim wording from the response
“scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 May 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
Make £1.6 billion available over two years to support timely and effective hospital discharge.

Verbatim wording from the response
“scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E, reducing delays in ambulances handing over patients so they can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 May 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 NHS England and healthcare partners to improve Category 2 ambulance response times.

Verbatim wording from the response
“We are continuing to work with NHSE and our other healthcare partners to improve our response times, particularly in relation to Category 2 calls. Please do not hesitate to contact me should you require any further information.”

Source location
Response from East of England Ambulance Service
Page 2 · response
Published 9 May 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
East of England Ambulance Service NHS Trust is best placed to respond on local actions to improve ambulance response times.

Verbatim wording from the response
“Your report raises concerns about the ambulance response times by East of England Ambulance Service NHS Trust (EEAST). You have raised these concerns directly with EEAST which is best placed to respond on the specific action being taken locally to improve response times. In preparing this response, Departmental officials have made enquiries with the Care Quality Commission who have also met EEAST to discuss the circumstances around Mr Bray’s death and local action being taken.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 May 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
Category 2 response-time performance is not an issue specific to this Trust, as action is required nationally and locally.

Verbatim wording from the response
“You acknowledge that action is being taken on both local and national levels in relation to the C2 response times (as this is not an issue specific to this Trust) however you have stated that the evidence from these actions is that these have been ineffective to date.”

Source location
Response from East of England Ambulance Service
Page 1 · response
Published 9 May 2024
Open published response
20 Feb2023
North Wales (East and Central)
Concerns raised1
1. Insufficient ambulance resource availability for timely attendance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Revisit the Clinical Safety Plan to address patient-safety risks when ambulances are unavailable.
  Stated by Welsh Ambulance Services NHS TrustStated completed
2. Action
  Continue monitoring, updating and presenting the Reducing Patient Harm Action Plan to the Trust Board.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
AI-generated summary

David Colin Strachan · 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

David Strachan developed sudden chest pain, vomiting, clamminess and shortness of breath at home on 15 March 2022. After multiple 999 calls, an ambulance and paramedics arrived only later that morning; he was diagnosed with an ST elevation myocardial infarction, transferred to hospital and died on 16 March 2022. The principal concern was delayed ambulance attendance associated with resource pressures and handover delays, with the report stating that significant concerns remained.

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
Insufficient ambulance resource availability for timely attendance
Wider context from the report
“The causes of the ambulance delay were that all available resources were managing incidents of a higher acuity or the same category but registered prior and there were significant handover delays across all BCUHB sites. The matters of concern herein are longstanding and multifactorial and despite proposed future action significant concerns remain. The Welsh Ambulance Service NHS Trust and Health Board maintain that they are continuing to work closely in order to address handover delays and yet any improvements appear extremely limited. Deaths are occurring and will continue to occur as a result of delayed ambulance attendances caused by these multifactorial issues. ”
Source location
David Colin Strachan · 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
Revisit the Clinical Safety Plan to address patient-safety risks when ambulances are unavailable.

Verbatim wording from the response
“when ambulances are unavailable. Additionally, we have shared with you the measures that are currently in place such as the Clinical Safety Plan and the Regional Escalation Action Plan. I will not repeat those within this response to you, however, the Clinical Safety Plan was revisited in December 2022 and I attach at appendix 1, a copy of the latest plan.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 27 February 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue monitoring, updating and presenting the Reducing Patient Harm Action Plan to the Trust Board.

Verbatim wording from the response
“The Trust has previously provided evidence to coroners pan-Wales regarding the actions that have been taken in order to reduce the lost hours and improve our response times for patients waiting in the community. In my response to you regarding Mrs. Glynis Roberts, I shared a copy of the Reducing Patient Harm Action Plan that had been tabled in our Trust Board meeting.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 27 February 2023
Open published response
4 Feb2023
Manchester South
Concerns raised1
1. Delays in ambulance availability
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Maintain additional ambulance capacity to expand provision and improve response times.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Provide 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.
  Stated by Department of Health and Social CareStated completed
1. Action
  Scale virtual ward capacity to more than 10,000 beds nationally.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide funding to support timely and effective discharge from hospital.
  Stated by Department of Health and Social CareStated completed
3. Action
  Continue working with NHS England to reduce ambulance response times.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Patricia Grace Eileen Green · Prevention of Future Deaths report

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

Report summary

Patricia Grace Eileen Green had an accidental fall at home and remained prone on the floor for nine hours while waiting for an ambulance. She deteriorated, including in her breathing, and later died in hospital from COVID-19 pneumonia, with the investigation noting the fall and prolonged time on the floor as contributing factors. Concerns included delays in ambulance response and emergency department assessment, linked to shortages, high demand and delays transferring patients from emergency departments.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in ambulance availability
Wider context from the report
“1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients; 2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest; 3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients. ”
Source location
Patricia Grace Eileen Green · 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
Maintain additional ambulance capacity to expand provision and improve response times.

Verbatim wording from the response
“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
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
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
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 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
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
Scale virtual ward capacity to more than 10,000 beds nationally.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
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 funding to support timely and effective discharge from hospital.

Verbatim wording from the response
“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
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 NHS England to reduce ambulance response times.

Verbatim wording from the response
“However, I recognise there is still more to do to reduce response times further, and the Government will continue to work with NHS England to achieve this.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
Open published response
25 Jan2023
Milton Keynes
Concerns raised1
1. Insufficient ambulance service resources for emergency response demand
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Rita Maureen TAYLOR · 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

Rita Maureen TAYLOR suffered an unwitnessed fall at home and a head injury. Multiple ambulance calls were made, but an ambulance was delayed because no resources were available; she arrived at hospital with a Glasgow Coma Score of 3 and died the same day. The principal concern was insufficient ambulance service resources and the resulting delay, which the inquest conclusion described as causing lost opportunities to admit her and begin treatment.

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
Insufficient ambulance service resources for emergency response demand
Wider context from the report
“I am concerned that there are insufficient ambulance service resources to meet the needs of the City of Milton Keynes. The first call to the 111 service was made at 10.28 and the call was deemed a category 3 incident. [At] that time there were "no available resources to send." At 11.12 a 999 call was made by a passer by but there were still "no available resources ". At 12.16 there was a further 999 call. The incident remained a category three and was "still pending in the dispatch queue waiting for resources to become available ". At 12.41 a call was made to Mrs. Taylor’s location but there were " still no available resources to send". At 13.12 A further 999 call was made " awaiting resources to become available" At 13.48 Patient location was called she was now in and out of consciousness and although she remained a category 3 an audit of the call decided that she should have been upgraded to a category 2 or 1. "Still no available resources". At 14.42 further 999 call but again "no available resources". At 15.25 Case reviewed to a category 2. At 16.29 An ambulance was dispatched arriving at 17.15. This was 6hours 47 minutes after the original call and 1hour 49 minutes after category 2 upgrade. Mrs Taylor arrived at the hospital at 17.57 and when assessed in the emergency department her Glasgow Coma score was recorded as 3.She died later the same day. ”
Source location
Rita Maureen TAYLOR · Prevention of Future Deaths report
Page 1 · concerns
Open source report
20 Jan2023
Gwent
Concerns raised1
1. Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Make funding available to support delivery of the national ambulance improvement plan.
  Stated by Eluned MorganStated completed
2. Action
  Conduct secondary triage of waiting patients, including Amber 1 calls, through the Clinical Support Desk to reassess or confirm priority.
  Stated by Welsh Ambulance Services NHS TrustStated completed
3. Action
  Expand Clinical Support Desk capacity, employ mental health practitioners, and implement clinical decision-support software for detailed patient assessment.
  Stated by Welsh Ambulance Services NHS TrustStated completed
1. Action
  Operate the Physician Triage Assessment and Streaming model across three health boards using upgraded Computer Aided Dispatch tools.
  Stated by Welsh Ambulance Services NHS TrustStated completed
2. Action
  Roll out the Physician Triage Assessment and Streaming model to additional health boards.
  Stated by Welsh Ambulance Services NHS TrustStated planned
3. Action
  Use welfare calls and Clinical Support Desk procedures to reassess waiting patients and upgrade calls when clinical conditions or prolonged waits warrant it.
  Stated by Welsh Ambulance Services NHS TrustStated completed
Respondent positions 1
1. Position
  Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.
  Stated by Eluned MorganRedirects responsibility
AI-generated summary

Dorothy Anne Jones · Prevention of Future Deaths report

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

Report summary

Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide ambulance resources to Amber 1 patients within a reasonable timeframe
Wider context from the report
“1. The ongoing pressures faced by the ambulance service are clearly multifactorial. However, a failure to provide a resource within a reasonable timeframe has been a constant and ongoing feature of inquests within Gwent, where a patient has died at home or shortly after admission to hospital. Despite repeated reassurances over the past 12 months about remedial action being undertaken, the evidence before me at this inquest suggests there has been no appreciable improvement in the response times for Amber 1 category patients. ”
Source location
Dorothy Anne Jones · 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
Make funding available to support delivery of the national ambulance improvement plan.

Verbatim wording from the response
“We have also made investments in ambulance services, including £3m funding made available in June 2022, to support delivery of a national ambulance improvement plan developed by the Emergency Ambulance Services Committee and approved by health board chief executives. The plan included a range of actions for delivery by the Welsh ambulance service, health boards and actions for joint delivery, to enable better management of 999 demand in the community, increased ambulance capacity and improved timeliness of ambulance patient handovers.”

Source location
Response from Minster for Health and Social Services
Page 2 · response
Published 24 January 2023
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 secondary triage of waiting patients, including Amber 1 calls, through the Clinical Support Desk to reassess or confirm priority.

Verbatim wording from the response
“In the live environment, WAST regularly undertakes more detailed clinical assessments of waiting patients, in all categories, including Amber 1; to reassess and/or confirm the correct priority for patients. This process, known as secondary triage or consultation is led by the Clinical Support Desk (CSD) which is a pan Wales team that comprise of control room nurses, paramedics, advanced paramedics, and mental health practitioners.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 2 · response
Published 24 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand Clinical Support Desk capacity, employ mental health practitioners, and implement clinical decision-support software for detailed patient assessment.

Verbatim wording from the response
“consultation. WAST has recently invested in the CSD by near doubling its establishment, employing mental health practitioners, and by implementing a new innovative clinical decision support system to support the more detailed clinical assessment of patients.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 3 · response
Published 24 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate the Physician Triage Assessment and Streaming model across three health boards using upgraded Computer Aided Dispatch tools.

Verbatim wording from the response
“WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 3 · response
Published 24 January 2023
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
Roll out the Physician Triage Assessment and Streaming model to additional health boards.

Verbatim wording from the response
“WAST has also invested in new versions of its Computer Aided Dispatch (CAD) tool, which allows health board Doctors to log in (remotely from the control rooms) to the waiting ambulance stack and undertake more detailed clinical assessments of patients in their health board. The Physician Triage Assessment and Streaming (PTAS) model is now operating across three of the health boards with plans to roll out further.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 3 · response
Published 24 January 2023
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 welfare calls and Clinical Support Desk procedures to reassess waiting patients and upgrade calls when clinical conditions or prolonged waits warrant it.

Verbatim wording from the response
“A copy of the CSP is attached for your reference and as you will see this provides details of when welfare calls should be made. These calls are made to reassess the patient’s clinical condition, if any changes are reported.”

Source location
Response from Welsh Ambulance Services NHS Trust
Page 3 · response
Published 24 January 2023
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
Operational concerns about ambulance service delivery are best addressed by the Welsh Ambulance Services Trust.

Verbatim wording from the response
“I note you have also written to ████████, Chief Executive of the Welsh Ambulance Services Trust and I would expect him to respond on the detail of the concerns you raised as these relate to operational matters and are best addressed by the Trust. I can, however, outline the actions being taken by the Welsh Government to drive national and local improvement in the delivery of safe and timely ambulance services.”

Source location
Response from Minster for Health and Social Services
Page 1 · response
Published 24 January 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in ambulance response and arrival

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays in ambulance attendance

Concerns raised1

Failure to maintain timely ambulance availability and arrival for patients

Concerns raised1

Failure to provide timely category 2 ambulance responses

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Concerns raised1

Delays in ambulances arriving to patients

Concerns raised1

Failure to provide timely ambulance responses to Category 2 calls

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 5

Respondent positions 2

Actions described in response 7

Actions described in response 9

Respondent positions 2