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.

6 Dec2019
Gateshead and South Tyneside
Concerns raised1
1. Delays in reacting meaningfully and promptly to presenting danger
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

MAUREEN WHARTON · 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

Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in reacting meaningfully and promptly to presenting danger
Wider context from the report
“The Investigation of the circumstances of the death has focused amongst other aspects on the control communications between Maureen and Ambulance control personnel with particular reference to the detail of the actual conversations had between Maureen and the personnel, the method of evaluating and grading of information elicited from Maureen in that process. It is correct to acknowledge the NEAS is still undertaking its own investigation and evaluation of these matters with a view to publishing a report before the end of the current year, concerns have been identified around apparent missed opportunities to react in a different or more timely manner to the facts and detail being presented in the course of these calls. Central to these concerns are that a period of 3.45 hours elapsed between the first call and the arrival of an Ambulance crew at Maureen’s flat. Whilst explanations around lack of resources and even possibly inadvertent allocation and/or interpretation of data may feature in the NEAS subsequent report by way of explanation of this delay, the real and imminent danger of Maureen’s admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way given the danger they clearly presented. An apparent toxicological aide was either unappreciated or misinterpreted as an under assessed and graduated event - the need was obvious a) No enquiry was made of Maureen as to the nature of her location and the potential support or assistance readily at hand or otherwise. b) No further enquiries were made to identify familial or social support which might or could have been enlisted or alerted to her presenting danger c) No NEAS protocol appears to exist to assist personnel to initiate a response other than one limited to and directing an ambulance allocation d) No working arrangement appears to exist to enlist the aid of other Agencies to support the patient or react more directly and in timely way to monitor and evaluate the nature of the presenting danger. There appears to be a need for a closer liaison and working relationship between Emergency Services which is sufficiently robust to react and present early support to the patient there having been such an accurate evaluation of an otherwise obvious developing critical situation and particularly if delays in reaction otherwise may also be apparent. ”
Source location
MAUREEN WHARTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Nov2019
Lincolnshire
Concerns raised1
1. Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded
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

Helen BARKER · 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

Helen BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.

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 escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded
Wider context from the report
“1. A serious level investigation report (reference SI 2018/27277) made 5 recommendations, the fifth appearing on page 15 which reads as follows:- Consider the feasibility of the CAT Team Leader making contact with NHS 111 when it is noted that there is an increase in the number of C3 coded calls that have not been assessed by a NHS 111 Clinician before being passed to the Trust. Has this recommendation now been implemented particularly where attempted suicides have been reported. Why can't EMAS escalate a category 3 status to a category 2 status when their own call out time of 120 minutes for an ambulance on a category 3 status has been exceeded? ”
Source location
Helen BARKER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Oct2019
Newcastle upon Tyne
Concerns raised1
1. Delay in ambulance dispatch
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Philip Richard Hayes · 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

Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based triage.

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
Delay in ambulance dispatch
Wider context from the report
“(1) Delay in ambulance dispatch Call categorised C2 received response 1 hour 2 minutes after original call ”
Source location
Philip Richard Hayes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Oct2019
Buckinghamshire
Concerns raised2
1. Failure of overdose call categorisation to ensure timely ambulance response
2. Failure to implement the local overdose response override at the outset
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
  Deploy Release 18, including the Dx0124 disposition code, to identify higher-risk suicide cases for early clinical review.
  Stated by NHS EnglandStated in progress
2. Action
  Develop a disposition code for symptomatic accidental-overdose patients, subject to National Clinical Governance Group review, to enable urgent clinical risk assessment.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Ambulance response standards and category mappings are set by NHS England, not by NHS Pathways.
  Stated by NHS EnglandRedirects responsibility
1. Position
  NHS Pathways cannot automatically identify higher-risk overdoses from drugs taken because closed questions cannot safely capture the relevant variables.
  Stated by NHS EnglandUnable to act
AI-generated summary

Alf REWIN · 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

Alf Rewin died at Wexham Park Hospital on 22 November 2018 after taking an overdose of Quetiapine, Methylphenidate and Duloxetine and becoming unresponsive before arrival. The principal concern was that overdose cases could receive a Category 3 ambulance response with a target of up to 120 minutes, despite the risk of unconsciousness, cardiac arrest or other potentially fatal events requiring earlier attendance.

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 of overdose call categorisation to ensure timely ambulance response
Wider context from the report
“The National Ambulance Call Categories prescribed by NHS Pathways to ambulance services, including South Central Ambulance Service, who were the attending service in relation to Alf Rewin's death, indicate that an individual contacting emergency services himself or herself, having taken an overdose may be triaged through the national call handling pathway to a Category 3 Urgent Call. This category currently prescribes a target ambulance within 120 minutes. There is a concern that in cases of overdose, the patient is at risk of becoming unconscious or having a cardiac arrest or other potentially fatal event and will be unable to contact emergency services or be contacted by them subsequently, such that his or her call should at that stage then be regarded as Category 1 (with a 7 minute response time) or Category 2 (with an 18 minute response time). In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute response in overdose cases to provide a specific triage which could lead to a Category 2 18-minute response (although the 18-minute response was not, in fact, implemented at the outset in Alf Rewin’s case and he was initially allocated the national Category 3 response). It is understood that the national categorisation of overdose cases is under review. Whilst the Category 3 120-minute target may be the standard, subject to local variation, in relation to overdose cases where the patient is conscious, the risk of deaths arising during this period remains where the circumstances of the overdose might enable some counteractive treatment to be given, or successful resuscitation measures to be carried out, if there were to be earlier attendance and / or earlier hospitalisation. ”
Source location
Alf REWIN · 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
Failure to implement the local overdose response override at the outset
Wider context from the report
“The National Ambulance Call Categories prescribed by NHS Pathways to ambulance services, including South Central Ambulance Service, who were the attending service in relation to Alf Rewin's death, indicate that an individual contacting emergency services himself or herself, having taken an overdose may be triaged through the national call handling pathway to a Category 3 Urgent Call. This category currently prescribes a target ambulance within 120 minutes. There is a concern that in cases of overdose, the patient is at risk of becoming unconscious or having a cardiac arrest or other potentially fatal event and will be unable to contact emergency services or be contacted by them subsequently, such that his or her call should at that stage then be regarded as Category 1 (with a 7 minute response time) or Category 2 (with an 18 minute response time). In Alf Rewin’s case, there existed a local policy to override the Category 3 120-minute response in overdose cases to provide a specific triage which could lead to a Category 2 18-minute response (although the 18-minute response was not, in fact, implemented at the outset in Alf Rewin’s case and he was initially allocated the national Category 3 response). It is understood that the national categorisation of overdose cases is under review. Whilst the Category 3 120-minute target may be the standard, subject to local variation, in relation to overdose cases where the patient is conscious, the risk of deaths arising during this period remains where the circumstances of the overdose might enable some counteractive treatment to be given, or successful resuscitation measures to be carried out, if there were to be earlier attendance and / or earlier hospitalisation. ”
Source location
Alf REWIN · 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
Deploy Release 18, including the Dx0124 disposition code, to identify higher-risk suicide cases for early clinical review.

Verbatim wording from the response
“Release 18 changes:”

Source location
2019-0469-Response-by-NHS-Digital
Page 6 · response
Published 7 October 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a disposition code for symptomatic accidental-overdose patients, subject to National Clinical Governance Group review, to enable urgent clinical risk assessment.

Verbatim wording from the response
“NHS Pathways has also recognised that those patients who have overdosed without suicidal intent and have symptoms (and so receive a Dx012 disposition and Category 3 ambulance) would benefit from having the same visibility within the Category 3 cohort as those with suicidal intent, so they can also be easily identified by clinicians working within ambulance control rooms for urgent remote clinical assessment of the risk to life. Further work by the NHS Pathways team is commencing in this area and, subject to review by the National Clinical Governance Group, a new disposition code will be introduced (similar to Dx0124) to enable this to occur. The Ambulance Response Programme will be made aware of this proposed change.”

Source location
2019-0469-Response-by-NHS-Digital
Page 7 · response
Published 7 October 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Ambulance response standards and category mappings are set by NHS England, not by NHS Pathways.

Verbatim wording from the response
“National ambulance call categories are not prescribed by NHS Pathways to ambulance services.”

Source location
2019-0469-Response-by-NHS-Digital
Page 3 · response
Published 7 October 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS Pathways cannot automatically identify higher-risk overdoses from drugs taken because closed questions cannot safely capture the relevant variables.

Verbatim wording from the response
“A) Assessment of drugs taken”

Source location
2019-0469-Response-by-NHS-Digital
Page 5 · response
Published 7 October 2019
Open published response
24 Jul2019
Nottinghamshire
Concerns raised1
1. Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event
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

Maureen Woods · Prevention of Future Deaths report

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

Report summary

Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event
Wider context from the report
“(1) Patients requiring an emergency ambulance response reporting symptoms consistent with a cardiac event, but who are not yet in cardiac arrest, may wait up to 40 minutes for a category 2 response in line with the current national response times. (2) To combat this perceived inadequacy in nationally agreed response times, the East Midlands Ambulance Service NHS Trust has developed an adjunct to the protocol by triaging all non-category 1 calls to upgrade calls such as Mrs Woods for a priority response. However, resources do not permit each and every call to be triaged, and Mrs Wood’s call was not triaged before she went into cardiac arrest. If the system for national response times is having to be supported by local adjuncts to the system, this rather suggests that the allocation of these calls in category 2 lies outside of clinical need. ”
Source location
Maureen Woods · Prevention of Future Deaths report
Page 2 · concerns
Open source report
31 May2019
Norfolk
Concerns raised1
1. Delays in ambulance arrival outside Trust guidelines
This report raised 4 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 1
1. Action
  Increase frontline ambulance staffing through recruitment, with 491 staff recruited and 270 further offers in process.
  Stated by EEASTStated in progress
AI-generated summary

Christopher Williams · 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

Christopher Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.

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 arrival outside Trust guidelines
Wider context from the report
“(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines. (2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm. (3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis. The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious. Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk. In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm, the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant. It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be addressed. ”
Source location
Christopher Williams · 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
Increase frontline ambulance staffing through recruitment, with 491 staff recruited and 270 further offers in process.

Verbatim wording from the response
“Following a review in April 2017 commissioned by NHS England and NHS Improvement recommendations were made on the best service model, pricing review, capacity and demand analysis and the commissioning/contract model. The review was undertaken by Deloittes and ORH, a company specialising in operational modelling for emergency and health services. The findings were published on the 11th May 2018 and recognised the resource gap between the existing funding for the Trust and what is needed to meet demand. This was factored in to our emergency operations contract with funding released to enable to increase front line staff by 330 full time equivalents by 2020/21.”

Source location
2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Page 1 · response
Published 14 August 2019
Open published response
25 Apr2019
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Delays in emergency response for patients with chest pains and related conditions
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.
Respondent positions 2
1. Position
  Amber 1 calls do not have planned four-hour delays, and self-transport advice is given only when clinically appropriate and safe.
  Stated by Welsh Ambulance Services NHS TrustDisputes the concern
1. Position
  Immediate vehicle allocation is not always possible when demand exceeds available ambulance supply.
  Stated by Welsh Ambulance Services NHS TrustUnable to act
AI-generated summary

Michael Jonathan Davies · 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 Jonathan Davies, aged 52, became unresponsive after contacting emergency services about pains down his arms and back and died at home before the ambulance arrived. The inquest recorded that he died from an acute myocardial infarction and that delayed medical treatment may have contributed to his death. The report raised concerns that chest pains and related conditions were categorised as Amber 1 rather than Red, resulting in a response time of up to four hours and potentially putting patients’ lives at risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in emergency response for patients with chest pains and related conditions
Wider context from the report
“1. During the course of the inquest the Welsh Ambulance Service Trust disclosed that in 2015 chest pains and related conditions were removed from the Red categorisation and placed in an Amber 1 categorisation whenever the patient is conscious and breathing. The inquest heard that in England (or in parts thereof) chest pains and related conditions remain as attracting a Category Red response. 2. The effect of removing chest pains and related conditions from Category Red is the response time, previously 8 minutes, is now up to 4 hours and often patients are advised to make their own way to hospital. 3. This puts patients’ lives at risk and in this inquest may have contributed to the death of Mr Davies. ”
Source location
Michael Jonathan Davies · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Amber 1 calls do not have planned four-hour delays, and self-transport advice is given only when clinically appropriate and safe.

Verbatim wording from the response
“With regard to point 2 of the Regulation 28 Report, I would like to take the opportunity to explain that Amber 1 calls do not attract a planned response of up to four hours within the clinical response model, nor is it correct to say that patients are often advised to make their own way to hospital. It would be right to say however that around 10% of all patients who dial 999 are offered advice by a senior clinician over the telephone which may include self-care advice or instructions to make their own way to a healthcare facility. This is only the case where it is clinically appropriate and safe to do so and supports the provision of sufficient emergency ambulance capacity being available to respond to those patients who do genuinely require such.”

Source location
2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 2 · response
Published 14 June 2019
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Immediate vehicle allocation is not always possible when demand exceeds available ambulance supply.

Verbatim wording from the response
“Whilst the Trust in its letter to ████████ and in the oral evidence provided at the inquest, acknowledges that there was a delay in an ambulance being allocated to Mr Michael Davies on 7 February 2018, this was an unavoidable delay. This is because at 11.25 hours when the call was received, and allocated the Amber 1 categorisation, there were no vehicles available to the Trust to send to Mr Michael Davies. This resulted in the open microphone call being made to all ambulances in the vicinity at 11.31 hours.”

Source location
2019-0134-Response-by-Welsh-Ambulance-Service-NHS-Trust
Page 3 · response
Published 14 June 2019
Open published response
24 Jan2019
Lincolnshire
Concerns raised1
1. Failure to meet response times
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 2
1. Action
  Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.
  Stated by East Midlands Ambulance Service NHS TrustStated completed
2. Action
  Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.
  Stated by East Midlands Ambulance Service NHS TrustStated in progress
AI-generated summary

Olive JOHNSON · 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

Olive JOHNSON died within 24 hours of admission to Pilgrim Hospital on 11 May 2018. The concerns raised relate to the absence of a first responder, emergency response times, how response delays were recorded after regrading, and whether EMAS had sufficient conveying resources to meet its targets.

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 meet response times
Wider context from the report
“b) How many occasions have EMAS exceeded their response times since 01/01/2108 to date? ”
Source location
Olive JOHNSON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Agree contract terms securing additional investment for clinical staff, ambulances and other response resources.

Verbatim wording from the response
“In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.”

Source location
2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 24 May 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Invest additional funding in clinical staff, ambulances and other resources to improve ambulance response times and consistency.

Verbatim wording from the response
“In 2018, new contract terms were agreed by the Trust with Hardwick Clinical Commissioning Group (CCG), providing extra investment during 2018-2019 and 2019-2020. Hardwick CCG which manages the EMAS contract on behalf of 22 CCGs across the region, signed off the terms for up to £9m funding for clinical staff, ambulances and other resources being provided in the first year. This could potentially rise to approximately £19m next year, dependent on performance targets being met and other financial agreements made as part of the contract terms.”

Source location
2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
Page 2 · response
Published 24 May 2019
Open published response
21 Dec2018
Gwent
Concerns raised1
1. Unavailability of nearby rapid response vehicles for calls outside red and amber 1 categories
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Commence an all-Wales demand and capacity review to determine required operational capacity and future service demand.
  Stated by Welsh Ambulance Services NHS TrustStated planned
2. Action
  Adopt a more dynamic approach to managing rapid response vehicles within each health board area.
  Stated by Welsh Ambulance Services NHS TrustStated completed
Respondent positions 1
1. Position
  Rapid response vehicles are reserved for immediately life-threatening calls, so lower-priority calls may wait longer.
  Stated by Welsh Ambulance Services NHS TrustExisting arrangements considered sufficient
AI-generated summary

Diane Greenslade · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of nearby rapid response vehicles for calls outside red and amber 1 categories
Wider context from the report
“(4) A rapid response vehicle had been based only eight minutes away from Mrs Greenslade’s home since at least 6.30 and had not responded to any calls as it was ring fenced for red and amber 1 calls. ”
Source location
Diane Greenslade · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Commence an all-Wales demand and capacity review to determine required operational capacity and future service demand.

Verbatim wording from the response
“3. Demand for ambulances was high compounded by excessive delays at hospitals. Unfortunately, this was the case and often has a material impact on our ability to respond in a timely and reasonable way to calls that are not immediately life threatening. As set out in the accompanying action plan, we are shortly to commence an all Wales demand and capacity review to establish exactly what operational capacity is required to ensure we respond in the majority of cases within set waiting time and quality standards. This work will also assess current demand for services and what we can expect to see in the next five years.”

Source location
2018-0401-Response-by-Welsh-Ambulance-Services
Page 4 · response
Published 21 December 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Adopt a more dynamic approach to managing rapid response vehicles within each health board area.

Verbatim wording from the response
“The Trust uses the Resource Escalation Action Plan or REAP to provide services during periods of increased demand or other NHS wide system pressures. The REAP is a UK agreed document used by all 13 NHS ambulance services, with some key actions and locally agreed operational tactics.”

Source location
2018-0401-Response-by-Welsh-Ambulance-Services
Page 3 · response
Published 21 December 2018
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Rapid response vehicles are reserved for immediately life-threatening calls, so lower-priority calls may wait longer.

Verbatim wording from the response
“One of the aims of REAP is to ensure that we have a resource available for a cardiac arrest or other high priority RED calls. In order to ensure this, the Trust reserves rapid response units for RED calls in REAP level 3 and 4. Whilst this means that some lower priority calls may wait longer for a response, it does ensure that we are always able to respond immediately to RED calls. I would like to assure you that we have reviewed”

Source location
2018-0401-Response-by-Welsh-Ambulance-Services
Page 3 · response
Published 21 December 2018
Open published response
2 Oct2018
South Wales Central
Concerns raised1
1. Lack of ambulance resources for timely attendance to critically unwell and deteriorating patients
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
  Ensure planned resources are sufficient to meet overall demand.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Align resource production with demand by location and time of day.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
3. Action
  Reduce sickness absence.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
1. Action
  Reduce handover-to-clear duration.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Introduce safe alternatives to responding at scene where appropriate.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
3. Action
  Reduce conveyance where safe and appropriate by providing care at home through advanced practitioners.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
4. Action
  Increase the scope of practice for Community First Responders.
  Stated by Welsh Ambulance Services NHS TrustStated planned
5. Action
  Complete a robust review of the Explorer Project.
  Stated by Welsh Ambulance Services NHS TrustStated completed
6. Action
  Strengthen out-of-hospital alternative pathways to improve care efficiency and resource use.
  Stated by Welsh Ambulance Services NHS TrustStated in progress
AI-generated summary

Andrew Collins · Prevention of Future Deaths report

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

Report summary

Andrew Collins became acutely unwell at home on 6 June 2018 with a severe headache, was found to have a subdural haematoma, underwent emergency neurosurgery, and died on 16 June 2018. The report raised concern about a delay of approximately three hours in sending an ambulance despite his rapidly deteriorating condition, attributed to a lack of available resources.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of ambulance resources for timely attendance to critically unwell and deteriorating patients
Wider context from the report
“(1) There was a delay of some 3 hours in sending an ambulance to Mr Collins when it was clear that his clinical picture was rapidly deteriorating. The first 999 call was received at 16:10 on the 6th June and correctly categorised but no vehicle was available to be dispatched to assist him. A further 999 call was made by his partner at 18:09 and again at 18:55 at which point he was described as “just about breathing and just about conscious”. An ambulance became available and was on scene at 19:10. He was conveyed to the University Hospital of Wales at 20:08 and handed over to hospital staff at 20:26. Whilst the evidence suggested the calls to the ambulance service were correctly categorised as having urgent clinical priority a clear lack of resources meant that there was a significant delay in attending to a critically unwell and deteriorating patient which, in my opinion must create a risk that further deaths may occur. ”
Source location
Andrew Collins · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ensure planned resources are sufficient to meet overall demand.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Align resource production with demand by location and time of day.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reduce sickness absence.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reduce handover-to-clear duration.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce safe alternatives to responding at scene where appropriate.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reduce conveyance where safe and appropriate by providing care at home through advanced practitioners.

Verbatim wording from the response
“The key initiatives that the Trust are continuing to working on, to deliver and enable an improved resourcing picture include, the following:”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 1 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase the scope of practice for Community First Responders.

Verbatim wording from the response
“The accompanying action plan will provide you with the detail of this work, in addition to other quality improvement initiatives designed to safely release resources to respond to patients in greatest need. This includes the introduction of a Falls Framework and increasing scope of practice for our Community First Responders.”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 2 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete a robust review of the Explorer Project.

Verbatim wording from the response
“In addition to the actions contained within the attached plan, the Trust has undertaken and completed a robust review of the “Explorer Project”. The aim of this was the introduction of “ring fencing” to stabilise resource capacity in the Cwm Taf area and to prevent the migration of emergency resources into busier adjacent Health Board areas.”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 2 · response
Published 6 March 2019
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen out-of-hospital alternative pathways to improve care efficiency and resource use.

Verbatim wording from the response
“I would like to reassure you that the Welsh Ambulance Services NHS Trust and Cwm Taf University Health Board, continue to work in collaboration to drive the improvements forward. We continue to strengthen the out of hospital alternative pathways to improve efficiency and effectiveness of care for our patients and make best use of our resources.”

Source location
2018-0336-Response-by-Welsh-Ambulance-Services-NHS-Trust
Page 2 · response
Published 6 March 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in reacting meaningfully and promptly to presenting danger

Concerns raised1

Failure to escalate category 3 ambulance requests to category 2 when the 120-minute call-out time is exceeded

Concerns raised1

Delay in ambulance dispatch

Concerns raised2

Failure of overdose call categorisation to ensure timely ambulance response

Failure to implement the local overdose response override at the outset

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

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

Concerns raised1

Category 2 ambulance response allocations outside clinical need for patients with symptoms consistent with a cardiac event

Concerns raised1

Delays in ambulance arrival outside Trust guidelines

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.1

Concerns raised1

Delays in emergency response for patients with chest pains and related conditions

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

Concerns raised1

Failure to meet response times

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

Concerns raised1

Unavailability of nearby rapid response vehicles for calls outside red and amber 1 categories

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

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

Concerns raised1

Lack of ambulance resources for timely attendance to critically unwell and deteriorating patients

Actions described in response 2

Respondent positions 2

Actions described in response 1

Respondent positions 2

Actions described in response 2

Actions described in response 2

Respondent positions 1