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Sophie HINDMARSH · Prevention of Future Deaths report View report

29 Apr 2024 South Yorkshire (Western) H. Berry

Sophie HINDMARSH had complex needs and required full-time care. After her father called 999 because she was vomiting brown liquid, felt hot to the touch and had a leaking feeding tube, the ambulance arrived 4 hours and 46 minutes after the call; concerns centred on delays in ambulance response and hospital handovers that reduced available ambulance resources.

Ronald William Bennett · Prevention of Future Deaths report View report

5 Apr 2017 Brighton and Hove G. Tisshaw

Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his death.

Graham Whiteley · Prevention of Future Deaths report View report

30 Jan 2025 Somerset V. McKinlay

Graham Whiteley, who had Alzheimer’s disease, a history of seizures and falls, and lived in a care home, walked out when doors were left unlocked and was found having fallen by the roadside with head injuries. He was conveyed to hospital by police after a substantial ambulance delay, developed pneumonia, and died in hospital on 18 June 2024. The principal concerns were delays in ambulance allocation linked to handover delays at acute hospitals, with the report stating that these delays were continuing.

Geoffrey Gordon Fuller · Prevention of Future Deaths report View report

18 Jun 2026 Cornwall and Isles of Scilly G. Davies

Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.

Nicola Emma OWENS · Prevention of Future Deaths report View report

31 Jan 2025 Liverpool and the Wirral A. Bhardwaj

Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.

JOHN SCOTT MURPHY · Prevention of Future Deaths report View report

22 Apr 2022 Manchester South L. Costello

John Scott Murphy, who had recently tested positive for Covid-19, deteriorated while alone at home and called the ambulance service at 03:20 on 11 July 2021. An ambulance arrived at 05:21, by which time he had died; the inquest concluded that the death was from natural causes, with Covid-19 pneumonitis and hypertensive heart disease recorded. The substantive concerns were delays in paramedics attending Category 2 calls due to staff and vehicle shortages, and ambulances being delayed at Accident and Emergency departments.

Mandeep SINGH · Prevention of Future Deaths report View report

23 Mar 2016 Teesside C. Bailey

Mandeep SINGH consumed high levels of alcohol and was found unconscious at home at approximately midnight after his wife found him lying on the floor. Although the ambulance call was assessed as R1 with a target response time of 8 minutes, the ambulance arrived after 27 minutes, and Mr Singh died in the ambulance. The investigation identified severe demand and staff shortages, as well as road closures and diversions, as factors in the delay.

Bobilya Mulonge · Prevention of Future Deaths report View report

8 May 2024 Manchester South L. Costello

Mrs Mulonge became unconscious after developing laboured breathing on 24 November 2022 and was found in cardiac arrest when an ambulance arrived 72 minutes after the call. She died later that day from congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus; the principal concern was that delays in ambulance response times had not been resolved within target ranges because ambulances could not be cleared from Accident and Emergency departments.

Lee Anthony CARUANA · Prevention of Future Deaths report View report

16 Jun 2022 Birmingham and Solihull E. Brown

Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.

Jade Marie GRIFFITHS-JONES · Prevention of Future Deaths report View report

17 Apr 2024 Birmingham and Solihull E. Brown

Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.

Geoffrey Douglas HOAD · Prevention of Future Deaths report View report

13 Sep 2023 Norfolk J. Lake

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.

Ricky O'Connell · Prevention of Future Deaths report View report

20 Aug 2025 Manchester South A. Mutch

Ricky O'Connell's overnight symptoms deteriorated and his partner called an ambulance, but it had not arrived by the time he collapsed. He was treated by his family and ambulance staff, transported to hospital, and died there on 27 January 2025. The principal concerns were significant ambulance delays, including delays caused by prolonged hospital handovers, high demand, and limited vehicle availability, with evidence that an ambulance should have arrived before he collapsed.

Lewis Aubrey GARFIELD · Prevention of Future Deaths report View report

28 Oct 2025 Northamptonshire H. Shah

Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.

Shaun PARKS · Prevention of Future Deaths report View report

20 Dec 2023 South Yorkshire (Western) K. Dickinson

Shaun PARKS attended Doncaster Royal Infirmary with a heart attack and waited for an ambulance transfer to the Northern General Hospital. He deteriorated and died during a procedure on 13 December 2022. Concerns included a 3-hour 18-minute ambulance response delay, insufficient emergency dispatch staffing, and hospital delays in offloading patients that reduced ambulance availability.

JAMES FREDERICK SMITH · Prevention of Future Deaths report View report

12 May 2025 Cornwall and Isles of Scilly G. Davies

James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance capacity.

CHARLES GEORGE EDWARD DEVOS · Prevention of Future Deaths report View report

10 Dec 2024 Cornwall and Isles of Scilly G. Davies

Charles George Edward Devos died at home on 9 January 2021 from an acute bowel condition after delayed clinical assessment following two 999 calls. The inquest found that the delay was a missed opportunity for potentially lifesaving treatment amid extreme operational pressure on ambulance services. The principal concerns were unallocated 999 calls, excessive ambulance delays, and reliance on measures such as self-conveyance, taxis and unattended emergency department drop-offs.

Angela Frances Darlow · Prevention of Future Deaths report View report

5 Feb 2026 North Wales (East and Central) K. Robertson

Angela Frances Darlow suffered a stroke at home on 6 January 2025, but an ambulance arrived 23 hours and 20 minutes later. She was diagnosed with an extensive left middle cerebral artery infarct, was not suitable for thrombectomy because of the delay, and died in hospital on 7 June 2025. The principal concern was the prolonged ambulance delay, in the context of high demand, hospital handover delays, patient flow and limited social care provision, resulting in lost opportunities for investigation and potential treatment.

David Colin Strachan · Prevention of Future Deaths report View report

20 Feb 2023 North Wales (East and Central) K. Sutherland

David Strachan developed sudden chest pain, vomiting, clamminess and shortness of breath at home on 15 March 2022. After multiple 999 calls, an ambulance and paramedics arrived only later that morning; he was diagnosed with an ST elevation myocardial infarction, transferred to hospital and died on 16 March 2022. The principal concern was delayed ambulance attendance associated with resource pressures and handover delays, with the report stating that significant concerns remained.

Diane Greenslade · Prevention of Future Deaths report View report

21 Dec 2018 Gwent W. James

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

BERNARD LESLIE GERRARD · Prevention of Future Deaths report View report

8 Mar 2018 Derby and Derbyshire R. Syed

Bernard Leslie Gerrard sustained injuries in an unwitnessed fall at the care home, was found to have a left fractured neck of femur, and died on 2 December 2017 despite treatment. The principal concern was a prolonged ambulance response, including delays to both the initial Category 3 response and the later Category 2 response, which EMAS attributed to insufficient resources and funding.