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.

30 Mar2015
Inner North London
Concerns raised2
1. Failure to address increasing ambulance response times
2. Failure to address increasing ambulance response times
This report raised 13 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 9
1. Action
  Review LAS operational performance weekly and agree additional actions to maintain resilience and improve ambulance response times.
  Stated by NHS EnglandStated completed
2. Action
  Commission and complete a diagnostic review of the key operational drivers of LAS underperformance, including utilisation and vehicle-hour constraints.
  Stated by NHS EnglandStated completed
3. Action
  Assure delivery of the LAS Improvement Programme through the NHS England LAS Oversight Group and regular assurance of the lead commissioner.
  Stated by NHS EnglandStated planned
1. Action
  Monitor LAS ambulance response-time and utilisation performance through the LAS Contracts and Performance Group during 2015/16.
  Stated by NHS EnglandStated planned
2. Action
  Recruit 850 staff, including approximately 150 new posts, to increase staffing and capacity.
  Stated by London Ambulance Service NHS TrustStated planned
3. Action
  Invest in new ambulance vehicles to increase operational capacity.
  Stated by London Ambulance Service NHS TrustStated planned
4. Action
  Reduce unnecessary multiple-vehicle dispatches through the agreed change programme.
  Stated by London Ambulance Service NHS TrustStated planned
5. Action
  Keep more ambulances operational and out of workshops through the agreed change programme.
  Stated by London Ambulance Service NHS TrustStated planned
6. Action
  Develop a non-emergency patient transport service for patients who do not need immediate clinical treatment.
  Stated by London Ambulance Service NHS TrustStated in progress
Respondent positions 1
1. Position
  The steps taken are considered sufficient to address the risk of future deaths from increasing ambulance response times.
  Stated by NHS EnglandNo action considered necessary
AI-generated summary

Sabrina Stevenson · 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

Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

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 address increasing ambulance response times
Wider context from the report
“(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed. ”
Source location
Sabrina Stevenson · 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 address increasing ambulance response times
Wider context from the report
“(1) Ambulance response times were the focus of evidence provided at the inquest. The most recent available response times show a worsening picture and submissions to date from LAS set out only a proposed ‘investment business case’ as to how resources can be freed-up. I have not been provided with the details of this proposal. I am not satisfied that sufficient steps have been taken to demonstrate that the risk of future deaths, from increasing response times, has been addressed. ”
Source location
Sabrina Stevenson · 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
Review LAS operational performance weekly and agree additional actions to maintain resilience and improve ambulance response times.

Verbatim wording from the response
“LAS undertook a number of steps to ensure the service remained resilient, safe and to secure improved ambulance response times in 2015. I will cover each step in turn:”

Source location
2015-0126-Response-by-NHS-England1
Page 2 · response
Published 30 March 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Commission and complete a diagnostic review of the key operational drivers of LAS underperformance, including utilisation and vehicle-hour constraints.

Verbatim wording from the response
“NHS England, London Region and TDA also commissioned a diagnostic review of the key drivers of underperformance. The key findings were that utilisation of the service had increased significantly so impacting on the operational capability of the service. Utilisation levels are driven by the number of Category A incidents, the job cycle time and the number of vehicle hours. During the last year, the level of Category A incidents had risen and available vehicle hours had reduced and the nominal net turnover rate was rising. The requirement to reduce utilisation rates became a key objective for securing medium and long term resilience of the service. The business case agreed by London CCGs and the TDA aims to improve ambulance response times on a sustainable basis by reducing vehicle utilisation to optimal levels.”

Source location
2015-0126-Response-by-NHS-England1
Page 2 · response
Published 30 March 2015
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
Assure delivery of the LAS Improvement Programme through the NHS England LAS Oversight Group and regular assurance of the lead commissioner.

Verbatim wording from the response
“NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG.”

Source location
2015-0126-Response-by-NHS-England1
Page 3 · response
Published 30 March 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Monitor LAS ambulance response-time and utilisation performance through the LAS Contracts and Performance Group during 2015/16.

Verbatim wording from the response
“NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG.”

Source location
2015-0126-Response-by-NHS-England1
Page 3 · response
Published 30 March 2015
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
Recruit 850 staff, including approximately 150 new posts, to increase staffing and capacity.

Verbatim wording from the response
“The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff re-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 2 · response
Published 30 March 2015
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 in new ambulance vehicles to increase operational capacity.

Verbatim wording from the response
“The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff re-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 2 · response
Published 30 March 2015
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 unnecessary multiple-vehicle dispatches through the agreed change programme.

Verbatim wording from the response
“A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 2 · response
Published 30 March 2015
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
Keep more ambulances operational and out of workshops through the agreed change programme.

Verbatim wording from the response
“A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 2 · response
Published 30 March 2015
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 non-emergency patient transport service for patients who do not need immediate clinical treatment.

Verbatim wording from the response
“A change programme has been agreed with commissioners, which includes initiatives such as reducing the number of vehicles sent to an incident when not needed, keeping more ambulances on the road and out of the workshop, working with the Metropolitan Police to better triage their calls for an ambulance, and developing a new non-emergency patient transport service for patients who do not need immediate clinical treatment, but do need to go to hospital.”

Source location
2015-0126-Response-by-London-Ambulance-Service
Page 2 · response
Published 30 March 2015
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
The steps taken are considered sufficient to address the risk of future deaths from increasing ambulance response times.

Verbatim wording from the response
“I was very sorry to learn of the death of Sabrina Stevenson through your Regulation 28 report. I hope that my response has given you assurance that NHS England has taken sufficient steps to demonstrate that the risk of future deaths, from increasing response times, has been addressed.”

Source location
2015-0126-Response-by-NHS-England1
Page 4 · response
Published 30 March 2015
Open published response
18 Mar2015
County Durham and Darlington
Concerns raised1
1. Inadequate cross-boundary emergency call routing and inter-service dispatch systems
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
  Review cross-border incident processes and systems.
  Stated by North East Ambulance Service NHS Foundation TrustStated completed
2. Action
  Review policies and procedures for liaising with adjoining emergency services when incidents occur on or near service borders.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
3. Action
  Review call-handling procedures for adjoining police and ambulance services and update direct control-room telephone access numbers.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
1. Action
  Send adjoining police forces and ambulance trusts letters explaining future call-processing changes.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
2. Action
  Discuss with the mobilising-system supplier how to deliver Direct Electronic Incident Transfer functionality.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated in progress
Respondent positions 5
1. Position
  Dispatching another ambulance service’s resource is undertaken by that service following a direct mutual-aid request, not through these systems.
  Stated by North East Ambulance Service NHS Foundation TrustRedirects responsibility
1. Position
  Emergency calls cannot technically be transferred directly between emergency services.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
2. Position
  Direct electronic incident transfer is unavailable because emergency services’ computer systems are incompatible.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
3. Position
  Resources cannot be directly dispatched from other fire services because their systems are disparate and resource-location protocols are absent.
  Stated by County Durham and Darlington Fire and Rescue ServiceUnable to act
4. Position
  Effective mutual assistance arrangements with adjoining fire services are considered sufficient despite the inability to dispatch their resources directly.
  Stated by County Durham and Darlington Fire and Rescue ServiceExisting arrangements considered sufficient
AI-generated summary

Grant Thomas Benson and Gordon Nicky Davidson · 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

Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.

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
Inadequate cross-boundary emergency call routing and inter-service dispatch systems
Wider context from the report
“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”
Source location
Grant Thomas Benson and Gordon Nicky Davidson · 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
Review cross-border incident processes and systems.

Verbatim wording from the response
“Following from the Regulation 28 report and recommendations sent to Yorkshire Ambulance Service and providing emergency services, I can confirm that the North East Ambulance Service has undertaken a review of our own processes and systems in respect of cross-border incidents.”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review policies and procedures for liaising with adjoining emergency services when incidents occur on or near service borders.

Verbatim wording from the response
“Following the Regulation 28 Report to Yorkshire Ambulance Service dated 19 March 2015, County Durham and Darlington Fire and Rescue Service (CDDFRS) have conducted a review of policies and procedures for liaising with the other border Blue Light Services when incidents occur on or near those adjoining borders.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review call-handling procedures for adjoining police and ambulance services and update direct control-room telephone access numbers.

Verbatim wording from the response
“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Send adjoining police forces and ambulance trusts letters explaining future call-processing changes.

Verbatim wording from the response
“7 Review of Call Handling Procedures Following receipt of the Regulation 28 Report CDDFRS have reviewed their call handling procedures for all adjoining Police and Ambulance Emergency Services. Letters have been sent to all adjoining Police Forces and”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Discuss with the mobilising-system supplier how to deliver Direct Electronic Incident Transfer functionality.

Verbatim wording from the response
“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Dispatching another ambulance service’s resource is undertaken by that service following a direct mutual-aid request, not through these systems.

Verbatim wording from the response
“6. Is it not possible for one ambulance service to dispatch an ambulance from another ambulance service?”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 2 · response
Published 18 March 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Emergency calls cannot technically be transferred directly between emergency services.

Verbatim wording from the response
“4 Transferring Calls from One Emergency Service to Another Currently it is not technically possible to transfer an emergency call from one emergency service to another. When calls are received in error for another Emergency Service, the Fire Service control room will log the call and take as many details from the caller as possible; at the same time another fire control operator will inform the relevant emergency service. Where necessary, and as appropriate, control operators will continue to speak to callers until it is known that assistance, from the attending emergency service, has arrived at the incident.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Direct electronic incident transfer is unavailable because emergency services’ computer systems are incompatible.

Verbatim wording from the response
“Direct Electronic Incident Transfer (DEIT) between emergency services is not as yet available as computerised mobilising/ incident recording systems within the individual control rooms are not compatible. Investigations into possible solutions are being investigated and pilots are being undertaken with various emergency services. CDDFRS are currently in talks with their mobilising system supplier to help deliver this functionality.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Resources cannot be directly dispatched from other fire services because their systems are disparate and resource-location protocols are absent.

Verbatim wording from the response
“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
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
Effective mutual assistance arrangements with adjoining fire services are considered sufficient despite the inability to dispatch their resources directly.

Verbatim wording from the response
“6 Dispatching Resources from another Emergency Service Due to the disparate nature of I.T systems in operation in other Fire and Rescue Services it is not possible to directly dispatch their resources. In addition, currently there are no protocols in place to view the locations of their resources in order to be able to mobilise them. Effective mutual assistance arrangements are, however, in place with all adjoining Fire and Rescue Services.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 2 · response
Published 18 March 2015
Open published response
19 Feb2015
Manchester South
Concerns raised1
1. Insufficient ambulance and staff capacity for timely ambulance response
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.
Respondent positions 2
1. Position
  Local commissioners are responsible for ensuring ambulance services receive sufficient funding for local population needs.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Individual ambulance Trusts are responsible for determining clinicians, vehicles and equipment needed to respond according to patients’ clinical needs.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Elizabeth Muriel Leah · 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

Elizabeth Muriel Leah, an 87-year-old care home resident with severe dementia, fell on 2 July 2014 and broke her femur. Although an ambulance was called, staff were advised to take her to hospital by taxi because of an anticipated ambulance delay. The principal concerns were insufficient ambulance and staffing capacity, delays transferring patients into emergency departments, and hospital bed-blocking.

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 and staff capacity for timely ambulance response
Wider context from the report
“On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi. This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi. When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time. This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems. These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government. ”
Source location
Elizabeth Muriel Leah · Prevention of Future Deaths report
Page 1 · 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
Local commissioners are responsible for ensuring ambulance services receive sufficient funding for local population needs.

Verbatim wording from the response
“I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.”

Source location
2015-0064-Response-by-Department-of-Health
Page 1 · response
Published 19 February 2015
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
Individual ambulance Trusts are responsible for determining clinicians, vehicles and equipment needed to respond according to patients’ clinical needs.

Verbatim wording from the response
“I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.”

Source location
2015-0064-Response-by-Department-of-Health
Page 1 · response
Published 19 February 2015
Open published response
12 Sep2014
North Wales (East and Central)
Concerns raised1
1. Delays in the provision of ambulance assistance
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 3
1. Action
  Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated planned
2. Action
  Review and align Welsh Medical Priority Dispatch System codes with other UK ambulance services using the system.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
3. Action
  Introduce a Wales-wide Clinical Desk staffed by paramedics and nurses to provide secondary triage and clinical support for delayed calls.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated planned
AI-generated summary

Clive Harold Turner · 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

Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.

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 the provision of ambulance assistance
Wider context from the report
“1. That there were significant delays in the provision of assistance to Mr Turner by the Welsh Ambulance Service ”
Source location
Clive Harold Turner · 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
Develop and implement a process for escalating delayed ambulance assessments to NHS Direct Wales for additional telephone clinical assessment.

Verbatim wording from the response
“To prevent this break down in communication in the future, the Trust has developed a clear process for escalating calls where a delayed face to face assessment (i.e. ambulance response) is offset by gaining additional clinical assistance from NHSDW, who can undertake a telephone assessment in the absence of an ambulance response. This will be in place from 1 December 2014.”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 2 · response
Published 12 September 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review and align Welsh Medical Priority Dispatch System codes with other UK ambulance services using the system.

Verbatim wording from the response
“Improvement to Call Prioritisation Like many other UK ambulance services, the Trust uses the international accredited Medical Priority Dispatch System (MPDS). This is a unified system for consistent call handling of”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 3 · response
Published 12 September 2014
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 a Wales-wide Clinical Desk staffed by paramedics and nurses to provide secondary triage and clinical support for delayed calls.

Verbatim wording from the response
“Clinical Desk The Trust is introducing a Clinical Desk into the Clinical Contact Centre in Vantage Point House, Cwmbran, which will be in operation for the whole of Wales. This will comprise of Paramedics and Nurses providing further early triage of calls using the Manchester Triage System to ensure the correct and most appropriate response is sent to meet the clinical needs of the patient. This will be implemented by the Trust in December 2014 and provides:”

Source location
2014-0404-Response-by-Welsh-Ambulance-Service
Page 4 · response
Published 12 September 2014
Open published response
31 Jul2014
Inner North London
Concerns raised1
1. Delays in paramedic response to intentional methadone overdose calls
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

Toni Elizabeth SKILLINGTON · 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

Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.

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 paramedic response to intentional methadone overdose calls
Wider context from the report
“4. London Ambulance Service received a call describing an intentional methadone overdose, teath with alcohol, and yet no paramedic responded until three hours later. ”
Source location
Toni Elizabeth SKILLINGTON · Prevention of Future Deaths report
Page 3 · concerns
Open source report
29 Jul2014
County Durham and Darlington
Concerns raised1
1. Delays in referring cases and dispatching ambulances after failure to obtain caller location information
This report raised 9 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

Gary William Million · 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

Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.

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 referring cases and dispatching ambulances after failure to obtain caller location information
Wider context from the report
“1. Once the 111 operator had failed to obtain detailed information about the callers location, there was a delay of some minutes before referring the matter to the Ambulance Trust and for the dispatch of an ambulance. ”
Source location
Gary William Million · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Apr2014
Exeter & Greater Devon
Concerns raised1
1. Failure to respond sufficiently seriously and promptly to mental health crisis calls
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
  Investigate the ambulance response to the relevant calls and complete the investigation report.
  Stated by SWASFTStated completed
2. Action
  Disseminate information on the correct process for arranging ambulance transport.
  Stated by SWASFTStated completed
3. Action
  Upgrade the NHS Pathways system to version 6.5.1 with a dedicated Mental Health Pathway.
  Stated by SWASFTStated completed
1. Action
  Train Clinical Hub staff, including new starters, to use the Mental Health Pathway through NHS Pathways training and scenarios.
  Stated by SWASFTStated completed
2. Action
  Establish a Mental Health Group to monitor responses to mental health concerns and develop policies, procedures and guidelines.
  Stated by SWASFTStated completed
AI-generated summary

Roger Clive DUGGAN · 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

Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

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 respond sufficiently seriously and promptly to mental health crisis calls
Wider context from the report
“(1) Whilst it was apparent in evidence that matters had reached fever pitch at Mr Duggan’s home, The Lindhay, The Old Farmhouse, Bramford Speke, on the evening of the 10th February 2013 as he reached a severe anxiety state. The family were firmly of the view the initial calls to Ambulance Control were not treated sufficiently seriously (despite the family being advised to do so by the Crisis Team). An ambulance visit only materialized after a further call to the Crisis Team and the latter’s instruction to Ambulance Control to attend. It appears that staff lacked the necessary training to deal with Mental Health Crisis. After subsequent arrival at the Royal Devon and Exeter Hospital (Wonford), Accident and Emergency Department, later that night 10th February 2013 Mr Duggan absconded only to be found deceased in the River Exe at 14.30 hours 12th February 2013. ”
Source location
Roger Clive DUGGAN · 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
Investigate the ambulance response to the relevant calls and complete the investigation report.

Verbatim wording from the response
“Following notification of the incident by Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG) the Trust conducted an investigation into the ambulance response to ████████ calls. This investigation was completed in May 2013 and forwarded to NEW Devon CCG for inclusion within the Serious Incident investigation which they led on. A meeting chaired by NEW Devon CCG, and attended by all agencies involved, subsequently took place to discuss the findings of the investigation and develop an action plan. A copy of the investigation report is appended to this letter, unfortunately this Trust was not aware that the inquest into Mr Duggan’s death was taking”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 1 · response
Published 7 April 2014
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
Disseminate information on the correct process for arranging ambulance transport.

Verbatim wording from the response
“The investigation concluded that there appeared to be a misunderstanding by the Crisis team on the correct procedure for requesting ambulance transport for patients who required assessment or have a pre-arranged admission which subsequently led to communication difficulties. Following the meeting chaired by NEW Devon CCG, information was disseminated regarding the correct process for arranging transport and would have resulted in an appropriate ambulance response.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
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
Upgrade the NHS Pathways system to version 6.5.1 with a dedicated Mental Health Pathway.

Verbatim wording from the response
“Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
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
Train Clinical Hub staff, including new starters, to use the Mental Health Pathway through NHS Pathways training and scenarios.

Verbatim wording from the response
“Following this incident, in July 2013, the Trust upgraded its version of ‘NHS Pathways’ to version 6.5.1 which included a dedicated Mental Health Pathway. This was developed in consultation with specialist Mental Health Teams and allows for patients with mental health symptoms to be dealt with more efficiently with the outcome of the triage (the disposition) being more appropriate. Prior to the implementation of version 6.5.1 all existing Clinical Hub staff were trained in the use of the Mental Health Pathway, this training is also provided for all new Clinical Hub staff as part of their ‘NHS Pathways’ training and includes scenarios.”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
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
Establish a Mental Health Group to monitor responses to mental health concerns and develop policies, procedures and guidelines.

Verbatim wording from the response
“In order to monitor the Trust’s response to patients with Mental Health concerns and develop robust policies, procedures and guidelines to improve the quality of care provided, a Mental Health Group has recently been established. This Group is chaired by a Trust Clinical Development Manager and is attended by managers from key areas of the Trust,”

Source location
2014-0157-Response-by-South-Western-Ambulance-Service
Page 2 · response
Published 7 April 2014
Open published response
24 Feb2014
North London
Concerns raised1
1. Failure to automatically link fall height, age and anti-clotting medication use to an eight-minute ambulance response
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

Graham James Sutton · 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

On 10 July 2013, Graham James Sutton fell five feet from a ladder while cutting a hedge, struck his head on concrete, and later died after being taken to hospital and transferred to a Trauma Centre. The concern was that the London Ambulance Service did not automatically link the fall, his age over 50, and his use of the anti-clotting medication Clopidogrel to a response within eight minutes.

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 automatically link fall height, age and anti-clotting medication use to an eight-minute ambulance response
Wider context from the report
“The fact that Mr Sutton had fallen as little as 5 feet, that he was over 50 years old and that he was taking anti-clotting medications, (Clopidogrel), were not linked automatically by the London Ambulance Service to result in a response within 8 minutes. ”
Source location
Graham James Sutton · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to address increasing ambulance response times

Failure to address increasing ambulance 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.9

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

Concerns raised1

Inadequate cross-boundary emergency call routing and inter-service dispatch systems

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.5

Concerns raised1

Insufficient ambulance and staff capacity for timely ambulance response

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 the provision of ambulance assistance

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.3

Actions described in response 9

Respondent positions 1

Actions described in response 5

Respondent positions 5

Respondent positions 2

Actions described in response 3