Recurring concern

Unreliable measurement of ambulance response times

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First reported 24 Jan 2019•Latest report 3 Oct 2024

Definition

What this concern includes

Includes failures in ambulance-service processes for defining, recording, calculating, aggregating or reporting response times, including omission of elapsed time after regrading and performance measures that conceal material response-delay spikes.

Not included

  • Excludes the underlying shortage of ambulances, crews or other response capacity where the measurement and reporting process is reliable.
  • Excludes ambulance call triage, dispatch, attendance and hospital handover failures when response-time measurement is not the deficient control.
  • Excludes general performance reporting unrelated to ambulance response times.
  • Excludes standards or prioritisation failures that do not also impair accurate measurement or reporting of response times.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2019–2024

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1
East Midlands Ambulance Service NHS Trust1

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.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Kevin George Woods · Prevention of Future Deaths report

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

    Report summary

    Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of average performance measures to reveal spikes in ambulance handover and response delays

    Wider context from the report

    “1) Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality. ”

    Source location

    Kevin George Woods · Prevention of Future Deaths report
    Page 4 · 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

    Healthcare providers are responsible for identifying and mitigating risks within their services through their own patient-safety processes.

    Verbatim wording from the response

    “The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 8 October 2024

    Open published response

  2. Lincolnshire

    AI-generated summary

    Olive JOHNSON · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to include time from the initial call to regrading in response-time measurement

    Wider context from the report

    “c) Is it fair that if a patient is regarded whilst awaiting an initial response the total time from the initial call to the regrading is cancelled out? ”

    Source location

    Olive JOHNSON · 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

    The response clock for re-categorised calls starts at regrading because this timing was decided from a national perspective.

    Verbatim wording from the response

    “c) Is it fair that if a patient is regraded whilst awaiting an initial response, the total time from the initial call to the regrading is cancelled out?”

    Source location

    2019-0031-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 24 May 2019

    Open published response
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Data last updated 7 September 2026