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Data updated 7 September 2026
Concerns 75
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Delays in ambulance-to-hospital patient handover
77 reports 53 recipients
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Delays in ambulance attendance
118 reports 66 recipients
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Failure to call an ambulance promptly when emergency assistance is required
37 reports 47 recipients
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Failure to maintain safe hospital patient flow
33 reports 28 recipients
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Failure to ensure timely ambulance access to care and emergency treatment premises
5 reports 13 recipients
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Inadequate system planning for ambulance-delay pressures
2 reports 3 recipients
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Unreliable ambulance stand-down decisions
3 reports 4 recipients
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Lack of overarching responsibility for patient safety risks from ambulance delays
2 reports 1 recipient
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Failure to provide timely emergency hospital conveyance
11 reports 21 recipients
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Failure to provide timely hospital admission
47 reports 56 recipients
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Failure to seek medical attention when a person's condition warrants it
56 reports 88 recipients
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Unreliable ambulance emergency escalation and contingency arrangements
5 reports 15 recipients
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Insufficient ambulance service capacity for emergency calls
58 reports 45 recipients
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Failure to provide timely clinical care
17 reports 29 recipients
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Unreliable allocation and referral of welfare support between police and ambulance services
5 reports 12 recipients
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Unreliable ambulance call triage and re-triage
50 reports 50 recipients
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Failure to dispatch emergency responders promptly to serious incidents
8 reports 10 recipients
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Unreliable ambulance response-time standards and prioritisation
13 reports 20 recipients
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Unreliable communication of ambulance dispatch status and expectations
13 reports 14 recipients
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Excessive emergency-department waiting times
7 reports 6 recipients
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Unreliable on-site emergency medical and first-aid response arrangements
33 reports 60 recipients
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Unreliable decisions about when ambulance attendance is required
12 reports 26 recipients
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Unreliable ambulance access through road closures and diversions
2 reports 2 recipients
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Failure to provide timely clinical review during ambulance call handling
6 reports 10 recipients
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Failure to provide timely ambulance-based treatment for suspected serious infection
2 reports 3 recipients
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Unreliable measurement of ambulance response times
2 reports 2 recipients
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Failure to reliably notify receiving hospital staff of ambulance arrivals
3 reports 6 recipients
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Unreliable category 3 ambulance assessment and response arrangements
7 reports 9 recipients
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Failure to provide timely medical review of emergency-department patients
8 reports 7 recipients
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Unreliable coordination of social-care-related patient flow
2 reports 8 recipients
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Failure of ambulance information systems to transfer safety-critical clinical and operational information
12 reports 20 recipients
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Insufficient mental health service capacity for timely patient care
40 reports 46 recipients
Reports 412
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Sophie HINDMARSH · Prevention of Future Deaths report
Related indexed information The ambulance service was called at 0245 on 21 July 2022 and the call was coded as a Category 2 at 0251 call requiring a response within 40 minutes. The ambulance finally arrived at 0731 on 21 July 2022, 4 hours and 46 minutes after the call. There was a significant delay in offloading patients at hospitals which tied up ambulance resource on that.
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Ronald William Bennett · Prevention of Future Deaths report
Related indexed information (1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of.
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Graham Whiteley · Prevention of Future Deaths report
Related indexed information c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Ho... d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers. g) The evidence.
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Geoffrey Gordon Fuller · Prevention of Future Deaths report
Coroner's concerns …in 2022 and 2023 by SWAST and the Healthcare Safety Investigation Branch (HSIB) found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found… “…..there is a direct…
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Nicola Emma OWENS · Prevention of Future Deaths report
Related indexed information The delay in an ambulance attending patients due to the unavailability of ambulances. A significant factor contributing to the handover delays in hospitals being the backlog of pat... On 07 October 2024 I commenced an investigation into the death of Nicola Emma OWENS aged 40. Backlog of patients fit for discharge awaiting social care packages.
Recipients 50
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Advanced Medical Priority Dispatch System (AMPDS)
1 report Latest 27 Jan 2022
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Emergency Call Prioritisation Advisory Group (ECPAG)
1 report Latest 24 Oct 2024
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West Midlands Ambulance Service University NHS Foundation Trust
NHS trust
15 reports Latest 10 Apr 2026
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Association of Ambulance Chief Executives
Health-sector membership body
37 reports Latest 16 Jun 2026
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Barking, Havering and Redbridge University Hospitals NHS Trust
NHS trust
28 reports Latest 10 Mar 2026
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South West Ambulance Service Trust (SWAST)
1 report Latest 18 Jun 2026
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Joint Royal Colleges Ambulance Liaison Committee
Health professional committee
8 reports Latest 10 Apr 2026
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Totally Urgent Care (incorporating Vocare)
1 report Latest 25 Sep 2023
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Premier Rescue Ambulance Service Ltd
1 report Latest 28 May 2021
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Hempsons (solicitors for East of England Ambulance NHS Trust)
1 report Latest 9 Apr 2014
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Melbourne Ambulance Station
1 report Latest 17 Jan 2019
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Milton Keynes Urgent Care Services CIC
1 report Latest 25 Jul 2025