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.

23 Nov2023
Cornwall and Isles of Scilly
Concerns raised1
1. Delays in ambulance 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 5
1. Action
  Publish the Delivery Plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Provide £1.6 billion over two years to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 1
1. Position
  SWAST and Royal Cornwall Hospital are best placed to respond on continuing local action to reduce handover delays and improve ambulance response times.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

KENNETH HEARD · 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

Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in ambulance response times
Wider context from the report
“(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro. (8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows: 5,107 hours lost at Derriford Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36 2,449 hours lost at Treliske Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13 (9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below. Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes Time Lost in June 2023 Time Lost in July 2023 Time Lost in August 2023 Derriford Hospital 4714:17 3436:41 5107:36 Treliske Hospital 2833:15 2386:23 2449:47 (10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000. (11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year. (12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above. ”
Source location
KENNETH HEARD · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the Delivery Plan for recovering urgent and emergency care services.

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 29 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 29 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver new ambulances and specialist mental health vehicles.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 29 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 29 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide £1.6 billion over two years to support timely and effective hospital discharge.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 29 November 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
SWAST and Royal Cornwall Hospital are best placed to respond on continuing local action to reduce handover delays and improve ambulance response times.

Verbatim wording from the response
“Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) and handover delays across the region. You have appropriately shared your report and concerns with SWAST and Royal Cornwall Hospital. SWAST and Royal Cornwall Hospital NHS Trust (RCHT), who are best placed to respond on the specific action they are continuing to take locally to reduce handover delays and improve ambulance response times.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 29 November 2023
Open published response
9 Nov2023
Suffolk
Concerns raised1
1. Lack of sufficient ambulance resource in Suffolk
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
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Helen WhatelyStated completed
2. Action
  Maintain additional ambulance capacity funded to expand capacity and improve response times, alongside delivering new ambulances and specialist mental health vehicles.
  Stated by Helen WhatelyStated in progress
3. Action
  Invest in expanding the ambulance workforce and support staff capacity.
  Stated by Helen WhatelyStated completed
AI-generated summary

Christopher Ivan HART · 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 Hart became unwell at home and an ambulance was requested, but no ambulance was immediately available because of high service demand and hospital off-loading delays. He was later found unresponsive and could not be resuscitated; the report states that his cardiac condition caused his death and that the ambulance delay directly contributed to it. The principal concern was continuing and regular ambulance non-availability in Suffolk and the wider East of England region, with insufficient ambulance resources potentially leading to future loss of life.

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 sufficient ambulance resource in Suffolk
Wider context from the report
“Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region. These periods of non-availability (in this case of over 8 ½ hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself. Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Christopher’s each year, identified that had an ambulance for Christopher arrived within the target time, the drugs he could have been given by ambulance personnel, and his early transport to hospital, would on a balance of probabilities have saved his life. I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life. ”
Source location
Christopher Ivan HART · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the delivery plan for recovering urgent and emergency care services.

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

Source location
2023-0453 Response from Department of Health and Social Care
Page 1 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain additional ambulance capacity funded to expand capacity and improve response times, alongside delivering new ambulances and specialist mental health vehicles.

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

Source location
2023-0453 Response from Department of Health and Social Care
Page 2 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Invest in expanding the ambulance workforce and support staff capacity.

Verbatim wording from the response
“Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to deliver services in ambulance and other care settings.”

Source location
2023-0453 Response from Department of Health and Social Care
Page 2 · response
Published 22 November 2023
Open published response
7 Nov2023
Suffolk
Concerns raised1
1. Lack of sufficient ambulance resource in Suffolk
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
  Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Gina Marie BYWATER · 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

Gina Marie Bywater became unwell with vomiting, shortness of breath and later chest pains, but an ambulance was not available for nearly 10 hours despite repeated 999 calls. She was found in cardiac arrest and subsequently died from a heart attack. The principal concern was the continuing lack of sufficient ambulance resources in Suffolk and the wider East of England, resulting in delays that the report states 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
Lack of sufficient ambulance resource in Suffolk
Wider context from the report
“Evidence heard from a Patient Safety Officer from the East of England Ambulance Service identified that, despite previous measures put in place, there are continuing and regular instances of non-availability of ambulances occurring in Suffolk and the wider East of England region. These periods of non-availability (in this case nearly 10 hours) fall far short of the target attendance times set by the East of England Ambulance Trust itself. Expert evidence from a Consultant Interventional Cardiologist, whose unit treats up to three thousand patients with serious cardiac issues such as Gina’s each year, identified that had an ambulance for Gina arrived within the target time, the drugs she could have been given by ambulance personnel, and her early transport to hospital, would on a balance of probabilities have saved her life. I am therefore concerned that the continuing lack of sufficient ambulance resource in Suffolk will lead to future loss of life. ”
Source location
Gina Marie BYWATER · 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
Provide £200 million in additional funding to ambulance trusts to expand capacity and improve response times.

Verbatim wording from the response
“Your report highlights that EEAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 13 November 2023
Open published response
7 Nov2023
Bedfordshire and Luton
Concerns raised1
1. Failure to provide allocated ambulance responses within the expected response time
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

Michael John VINCENT · 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 John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide allocated ambulance responses within the expected response time
Wider context from the report
“Mr Vincent had fallen many hours prior to making his first call to the ambulance service. There then followed a further ten hour delay, during which time he had a cardiac arrest, before he was admitted to the Emergency Department. He had been allocated an appropriate response time, expected within 18 minutes at 1929 on the 19th December 2022. For the reasons given in the circumstances above, that target was missed by an enormous margin. There is a strong possibility, even arguably a probability that another frail, elderly individual, will have the same experience. Long lie after a fall, especially in the elderly often results in a terminal kidney injury and death. Consideration should be given to review of how these types of emergency call are managed and thereafter monitored. ”
Source location
Michael John VINCENT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Sep2023
Norfolk
Concerns raised2
1. Delays in ambulance response to calls
2. Continuing delays in ambulance attendance to calls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Provide additional ambulance funding to expand capacity and improve response times, maintaining the additional capacity in 2024/25.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStatus unclear
3. Action
  Continue working with NHS England to reduce ambulance response times.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

John Trevor WINSWORTH · 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

John Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to 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
Delays in ambulance response to calls
Wider context from the report
“1. The ambulance service was called at 11.55 hours on 14 February 2023 and the call was graded as a Category 3 call, requiring a response within 2 hours. The ambulance arrived at 09.30 hours on 15 February 2023. The time between calling the ambulance and the ambulance arriving on scene was in excess of 19 hours. ”
Source location
John Trevor WINSWORTH · 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
Continuing delays in ambulance attendance to calls
Wider context from the report
“3. Considerable delays in attendance by EAST (East of England Ambulance Service Trust) to calls continues. ”
Source location
John Trevor WINSWORTH · 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
Provide additional ambulance funding to expand capacity and improve response times, maintaining the additional capacity in 2024/25.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 5 October 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver new ambulances and specialist mental health vehicles.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 5 October 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with NHS England to reduce ambulance response times.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 5 October 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the delivery plan for recovering urgent and emergency care services.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 5 October 2023
Open published response
13 Sep2023
Norfolk
Concerns raised3
1. Continuing delays in ambulance attendance
2. Delays in ambulance responses to calls
3. Continuing delays in ambulance service attendance to calls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Maintain additional ambulance capacity funded to expand capacity and improve response times.
  Stated by Department of Health and Social CareStated completed
3. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Continue working with NHS England to reduce ambulance response times.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Recruit over 300 additional frontline clinicians by March 2024 to increase ambulance capacity.
  Stated by East of England Ambulance Service NHS TrustStated planned
3. Action
  Increase patient-facing clinical hours in Norfolk and Waveney.
  Stated by East of England Ambulance Service NHS TrustStated completed
4. Action
  Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
  Stated by East of England Ambulance Service NHS TrustStated in progress
5. Action
  Share hospital handover good practice and work with acute hospitals to review processes and suggest quicker patient offloads.
  Stated by East of England Ambulance Service NHS TrustStated completed
6. Action
  Run a Norfolk and Waveney improvement week with clinical teams, crews, dispatchers and call handlers to identify causes and solutions for patient delays.
  Stated by East of England Ambulance Service NHS TrustStated completed
Respondent positions 1
1. Position
  Specific local action to reduce ambulance response times is assigned to EEAST and Norfolk and Norwich University Hospitals NHS Foundation Trust.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Geoffrey Douglas HOAD · 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

Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.

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
Continuing delays in ambulance attendance
Wider context from the report
“1. Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours. 2. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call. 3. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes. 4. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours. 5. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours. 6. Evidence was heard as to the very high call demand overnight on the 6th and 7th August 2022 and with regard to the significant pressure the healthcare system was and remains under. 7. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system. 8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue. ”
Source location
Geoffrey Douglas HOAD · 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
Delays in ambulance responses to calls
Wider context from the report
“8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue. The Trust is of the view that only by reducing system pressures as a whole, including hospital handover delays and community services being able to deal with their patients, will pressure on the ambulance service be alleviated to enable them to respond effectively and in a timely manner to their patients. This is to a great extent outside the control of the regional EEAST. ”
Source location
Geoffrey Douglas HOAD · 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
Continuing delays in ambulance service attendance to calls
Wider context from the report
“8. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue. ”
Source location
Geoffrey Douglas HOAD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response
“As the Minister responsible for urgent and emergency case services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to reduce Category 2 response times (including for serious conditions such as heart attacks and strokes) to 30 minutes on average this year. The plan is available at: https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain additional ambulance capacity funded to expand capacity and improve response times.

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver new ambulances and specialist mental health vehicles.

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with NHS England to reduce ambulance response times.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Recruit over 300 additional frontline clinicians by March 2024 to increase ambulance capacity.

Verbatim wording from the response
“The Trust has a range of specific actions in place to improve response times to patients which include:”

Source location
Response from East of England Ambulance Service NHS Trust
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase patient-facing clinical hours in Norfolk and Waveney.

Verbatim wording from the response
“- Additional recruitment with the aim for there to be over 300 more frontline clinicians in place by March 2024. Year on year we have increased patient facing hours by around 9% in Norfolk and Waveney.”

Source location
Response from East of England Ambulance Service NHS Trust
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.

Verbatim wording from the response
“- The implementation of our Operational Performance and Improvement Plan (OPIP) which is our plan to improve our own efficiency as an organisation and to maximise ambulance availability, I attach a presentation on this with this letter to provide an update on this work.”

Source location
Response from East of England Ambulance Service NHS Trust
Page 1 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Share hospital handover good practice and work with acute hospitals to review processes and suggest quicker patient offloads.

Verbatim wording from the response
“EEAST are a member of the Front Door Group looking to improve arrival to handover times. This is chaired by the Deputy Director for Intensive Support from the NHSE/I team. We have shared good practice from West Suffolk and Colchester Hospitals within the group, which is attended by all Acute in the area. EEAST have approached each Acute to review the current process and suggested changes to allow quicker offloads.”

Source location
Response from East of England Ambulance Service NHS Trust
Page 2 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Run a Norfolk and Waveney improvement week with clinical teams, crews, dispatchers and call handlers to identify causes and solutions for patient delays.

Verbatim wording from the response
“EEAST has also been involved in an ‘improvement Week’ which ran between the 9th and 13th October 2023 in Norfolk and Waveney. The clinical teams have been working alongside crews, dispatchers, and call handlers to better understand the issues behind delays for patients and helping identify ways to resolve them.”

Source location
Response from East of England Ambulance Service NHS Trust
Page 2 · response
Published 15 September 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Specific local action to reduce ambulance response times is assigned to EEAST and Norfolk and Norwich University Hospitals NHS Foundation Trust.

Verbatim wording from the response
“Your report raised concerns about the response time performance of East of England Ambulance Service NHS Trust (EEAST). I note that you have raised these concerns with EEAST and Norfolk and Norwich University Hospitals NHS Foundation Trust who are best placed to respond on the specific action being taken locally to support reduced ambulance response times.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
Open published response
2 Aug2023
South Yorkshire (Western)
Concerns raised1
1. Failure to provide timely category 2 ambulance responses
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 10
1. Action
  Improve ambulance response times for Category 2 incidents.
  Stated by NHS EnglandStated in progress
2. Action
  Increase ambulance capacity by growing the workforce.
  Stated by NHS EnglandStated in progress
3. Action
  Publish operational-resilience guidance focused on improving accident-and-emergency and ambulance handover times.
  Stated by NHS EnglandStated completed
1. Action
  Publish the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide and maintain additional ambulance capacity through dedicated funding.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
4. Action
  Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.
  Stated by Department of Health and Social CareStated completed
5. Action
  Scale up virtual ward capacity to more than 10,000 beds nationally.
  Stated by Department of Health and Social CareStated completed
6. Action
  Provide £1.6 billion over two years to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated completed
7. Action
  Continue working with NHS England to reduce ambulance response times.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Lee Dryden · 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

Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide timely category 2 ambulance responses
Wider context from the report
“2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee. ”
Source location
Lee Dryden · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve ambulance response times for Category 2 incidents.

Verbatim wording from the response
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase ambulance capacity by growing the workforce.

Verbatim wording from the response
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish operational-resilience guidance focused on improving accident-and-emergency and ambulance handover times.

Verbatim wording from the response
“In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks title Delivering operational resilience across the NHS this winter. This included focusing on improvements around Accident & Emergency handover and ambulance handover times.”

Source location
Response from NHS England
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response
“Your report also raised concerns about response times by Yorkshire Ambulance Service NHS trust (YAS) including the impacts of handover delays. I note NHS England also responded on the action they are taking in relation to this concern. As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’, which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to reduce Category 2 ambulance response times to 30 minutes on average. The plan is available at B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf (england.nhs.uk)”

Source location
Response from DHSC
Page 1 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide and maintain additional ambulance capacity through dedicated funding.

Verbatim wording from the response
“Your report highlights that YAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new”

Source location
Response from DHSC
Page 1 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“Your report highlights that YAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new”

Source location
Response from DHSC
Page 1 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.

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

Source location
Response from DHSC
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Scale up virtual ward capacity to more than 10,000 beds nationally.

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

Source location
Response from DHSC
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide £1.6 billion over two years to support timely and effective hospital discharge.

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

Source location
Response from DHSC
Page 2 · response
Published 4 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with NHS England to reduce ambulance response times.

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

Source location
Response from DHSC
Page 2 · response
Published 4 August 2025
Open published response
21 Jul2023
Manchester South
Concerns raised1
1. Delays in ambulance attendance for patients requiring clinical assessment
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 3
1. Action
  Improve ambulance response times through the urgent and emergency care recovery plan.
  Stated by NHS EnglandStated in progress
2. Action
  Increase ambulance capacity by growing the workforce.
  Stated by NHS EnglandStated in progress
3. Action
  Achieve Ambulance Response Programme standards across the North West region.
  Stated by NHS EnglandStated planned
AI-generated summary

Albert Dovey · 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

Albert Dovey suffered an accidental fall at home and was admitted to hospital with rhabdomyolysis, acute kidney injury, heart failure and a fractured clavicle. He became gravely frail and died at Tameside General Hospital on 4 February 2023. The inquest heard concerns about delays in ambulance attendance, ambulance processing at hospital and clinical assessment, with evidence that delays in treating elderly frail patients after a fall increased the risk of 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
Delays in ambulance attendance for patients requiring clinical assessment
Wider context from the report
“The inquest heard evidence that in relation to Mr Dovey there had been delays in him being assessed by clinicians due to delays in the ambulance attending after he was found on the floor and due to delays for ambulances to be processed at the hospital. The ambulance Mr Dovey was in a queue behind other ambulances waiting to unload patients into A and E. The inquest heard evidence that delays in treatment of elderly frail patients following a fall gave rise to an increased risk of death. In Mr Dovey’s case the delays were due to the sustained pressure on services across Greater Manchester which had been ongoing for months at the time of Mr Dovey’s death. The pressure was due to demand against availability of resources. ”
Source location
Albert Dovey · 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
Improve ambulance response times through the urgent and emergency care recovery plan.

Verbatim wording from the response
“performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 2 · response
Published 28 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase ambulance capacity by growing the workforce.

Verbatim wording from the response
“performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 2 · response
Published 28 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Achieve Ambulance Response Programme standards across the North West region.

Verbatim wording from the response
“Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the ARP standards in the region.”

Source location
Response from NHS England
Page 2 · response
Published 28 July 2023
Open published response
19 Jul2023
Manchester South
Concerns raised1
1. Delays in ambulance attendance for frail elderly patients with hip fractures
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Publish a two-year delivery plan to recover urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide £200 million of additional ambulance funding to expand capacity and improve response times.
  Stated by Department of Health and Social CareStated completed
3. Action
  Maintain the additional ambulance capacity during 2024/25.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStatus unclear
2. Action
  Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.
  Stated by Department of Health and Social CareStated completed
3. Action
  Maintain the hospital bed capacity uplift during 2024/25.
  Stated by Department of Health and Social CareStated in progress
4. Action
  Scale up national virtual ward capacity to more than 10,000 beds.
  Stated by Department of Health and Social CareStated completed
5. Action
  Provide £1.6 billion over two years to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated completed
6. Action
  Review ambulance performance regularly through the regional Strategic Partnership and Transformation Board and work towards achieving Ambulance Response Programme standards.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
AI-generated summary

Bernhard John Marek · 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

Bernhard John Marek sustained an accidental fall, suffered a fractured neck of femur, and died in hospital on 6 January 2023 after developing pneumonia. Concerns included prolonged ambulance waits for frail elderly patients with hip fractures and delays in ambulances offloading patients at emergency departments.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in ambulance attendance for frail elderly patients with hip fractures
Wider context from the report
“The inquest was told that the wait time that was given at the time of the initial call was due to demand on the ambulance service and that such delays were not unusual throughout December due to demand and resources. As a consequence frail elderly patients such as Mr Marek with hip fractures were regularly waiting significant periods of time for the ambulance service. ”
Source location
Bernhard John Marek · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish a two-year delivery plan to recover urgent and emergency care services.

Verbatim wording from the response
“I recognise the significant pressure the urgent and emergency care system is facing. In January 2023 we published our ambitious 2-year Delivery plan for recovering urgent and emergency care services to drive sustained improvements in urgent and emergency care waiting times. Our ambitions for this year are to improve A&E waiting times to a minimum of 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2304-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide £200 million of additional ambulance funding to expand capacity and improve response times.

Verbatim wording from the response
“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain the additional ambulance capacity during 2024/25.

Verbatim wording from the response
“£200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“£200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver 5,000 additional staffed, permanent hospital beds compared with 2022/23 plans.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain the hospital bed capacity uplift during 2024/25.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Scale up national virtual ward capacity to more than 10,000 beds.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide £1.6 billion over two years to support timely and effective hospital discharge.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review ambulance performance regularly through the regional Strategic Partnership and Transformation Board and work towards achieving Ambulance Response Programme standards.

Verbatim wording from the response
“████████est, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the ARP standards in the region.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 21 July 2023
Open published response
19 Jul2023
Manchester South
Concerns raised1
1. Delays in ambulance transfer to hospital for elderly frail patients with hip fractures
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 3
1. Action
  Improve ambulance response times through the urgent and emergency care recovery plan.
  Stated by NHS EnglandStated in progress
2. Action
  Increase ambulance capacity by growing the workforce.
  Stated by NHS EnglandStated in progress
3. Action
  Achieve the Ambulance Response Programme standards in the region.
  Stated by NHS EnglandStated planned
AI-generated summary

Evelyn Mary Dutton · 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

Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.

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 transfer to hospital for elderly frail patients with hip fractures
Wider context from the report
“1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day. Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available; 2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022. ”
Source location
Evelyn Mary Dutton · 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
Improve ambulance response times through the urgent and emergency care recovery plan.

Verbatim wording from the response
“NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all ambulance call categories than before the pandemic, as well as issues associated with handing over ambulance patients in a timely way as well as the flow of patients in and out of some NHS Trusts. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase ambulance capacity by growing the workforce.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Achieve the Ambulance Response Programme standards in the region.

Verbatim wording from the response
“Within the North West, ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region. We acknowledge that there remains work to be done to improve NWAS performance but are committed to achieving the Ambulance Response Programme’s standards in the region.”

Source location
Response from NHS England
Page 2 · response
Published 21 July 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in ambulance response 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.5

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 sufficient ambulance resource in Suffolk

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

Concerns raised1

Lack of sufficient ambulance resource in Suffolk

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

Failure to provide allocated ambulance responses within the expected response time

Concerns raised2

Delays in ambulance response to calls

Continuing delays in ambulance attendance to calls

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

Concerns raised3

Continuing delays in ambulance attendance

Delays in ambulance responses to calls

Continuing delays in ambulance service attendance to calls

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

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

Actions described in response 5

Respondent positions 1

Actions described in response 3

Actions described in response 1

Actions described in response 4

Actions described in response 9

Respondent positions 1