Ambulance Handover Delays
Significant delays in ambulance response times caused by prolonged patient offloading at hospitals, tying up critical resources.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
308 PFD reports
12 committee recs
6 HSSIB recs
22 CQC actions
6 PPO recs
4 IOPC recs
2 IMB recs
2 IMB reports
1 Article 2 learning point
1 DHR rec
67 PHSO decisions
200 LGO/SPSO decisions
3 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
FENN-32 — Improve LAS procedures for timing and recording ambulance whereabouts
Recommendation: The London Ambulance Service shall improve its procedures for timing and recording the whereabouts of its ambulances.
Unknown
P2-30 — Ambulance data on conveying deceased
Recommendation: Data on how often deceased patients are conveyed in ambulances, and the reasons for this, should be routinely collected and reported to NHS England, and monitored to assess risk.
Gov response: NHS England has confirmed that relevant data lines are in the information standard. The first routine collection is expected to be rolled out in 2026 to 2027.
Accepted
Prevention of Future Deaths reports(308)— showing 50 strongest matches
Lucy Hannah Rose Bailey
Concerns: The coroner identified that paramedic training and guidelines prohibit gentle internal manipulation or traction during childbirth, which may hinder effective assistance in cases of dystocia. Concerns were raised that amending these guidelines could reduce the risk of injury during birth.
Response (South Central Ambulance Service): • A review of the UK ambulance service clinical practice guidance on the management of shoulder dystocia was undertaken. • The guidance was updated with advice and input from specialists … (AI summary)
Responded
Michael Sweeney
Concerns: The coroner noted that the police use of 'excited delirium' is not widely understood by health services, potentially hindering proper diagnosis of medical emergencies. It was recommended that police training, control staff, and ambulance protocols be amended to use 'extreme agitation' to describe such conditions, ensuring appropriate prioritisation.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) and London Ambulance Service (LAS) have adopted 'Acute Behavioural Disorder' (ABD) as the common terminology for the constellation of symptoms, which is embedded in … (AI summary)
Response (London Ambulance Service): • The London Ambulance Service (LAS) stated it did not agree with the recommendation to amend its protocols and training to recognise 'extreme agitation' as a medical emergency, indicating it … (AI summary)
Responded
David Selman
Concerns: The coroner raises concerns about miscommunication between the control room and ambulance staff regarding instructions to 'stand down' versus 'stand back', and the lack of continual assessment of a patient's symptoms to ensure appropriate ambulance deployment.
Overdue
Barnabas Newlyn
Concerns: The coroner noted that road transfer times for critically ill patients, especially neurosurgical emergencies, between distant hospitals and specialist facilities may not allow sufficient time for life-saving interventions. Healthcare staff needing urgent transfers were advised to consider air transfer first.
Response (NHS England): • Interim guidance will be issued to acute hospitals within the next month, covering the maintenance of equipped transfer bags, correct protocols for uncommon events, and training for critical care … (AI summary)
Responded
Chloe Grace Flavell
Concerns: The coroner noted concerns regarding the management of the reception area before triage, which could lead to significant delays in providing immediate care, particularly for children. A more appropriate and efficient system is needed to minimise these delays.
Overdue
Albert James Hand
Concerns: Concerns were raised about a patient with a head injury waiting over 90 minutes for ambulance conveyance. The coroner noted insufficient ambulance crews in the area and protocols for emergency calls that may put patients at risk.
Response (East of England Ambulance Service NHS Trust): • The Trust commissioned a Clinical Capacity Review and shared its findings with Clinical Commissioning Groups to address ambulance availability. • The Trust initiated a recruitment drive to increase staff … (AI summary)
Responded
Mary Waldron
Concerns: Nursing home staff failed to recognise an acutely unwell resident or act on low blood pressure, exacerbated by a lack of ongoing training. Managers also did not effectively investigate incidents and provided inaccurate reports to the Care Quality Commission.
Overdue
Frederick Pring
Concerns: The coroner noted unacceptable delays in patient handover from ambulances to the Emergency Department, which results in ambulance resources being unavailable for other calls.
Response (Welsh Ambulance Service NHS Trust): • Advanced Paramedic Practitioners have been introduced in Clinical Contact Centres. • Arrangements have been made with Health Boards for staff to take main breaks in hospitals and other NHS … (AI summary)
Responded
Keith Thomas Graham
Concerns: The coroner called for a review of procedures for seriously injured trauma patients at A&E, specifically regarding the summoning of on-call clinicians, CT scanning protocols, and reducing delays between patient presentation and surgery.
Overdue
Caroline Pilkington
Concerns: North West Ambulance Service personnel are not trained in control and restraint techniques, leading to calls for police assistance with unwell patients. This can result in clinically unwell patients being handled by non-clinically trained police and delays in hospital transport.
Response (Greater Manchester Police): • Greater Manchester Police's revised officer safety training programme emphasizes recognizing medical risks and treating situations as medical emergencies. • Greater Manchester Police offered to support North West Ambulance Service … (AI summary)
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) stated that advanced control and restraint training for its staff is not feasible or safe due to the specialised nature of the skill and … (AI summary)
Response (Department of Health): • The Department of Health noted the existence of a joint protocol, established in March 2012, between North West Region Police Forces and NWAS for inter-agency working regarding patients requiring … (AI summary)
Response (Department of Health2): • NWAS confirmed that a regional protocol with police forces is in place and under review. • NWAS presented the inquest findings at the North West Police Regional Mental Health … (AI summary)
Responded
Sally Perrons
Concerns: The coroner highlighted concerns about the adequacy of paramedic intubation training and the mandatory use, availability, and training for waveform end-tidal carbon dioxide monitors in ambulance services. Separately, the report noted issues with EMAS's dissemination of new guidelines to frontline staff.
Response (Association Ambulance Chief Executives): • The National Ambulance Sector committed to developing a national teaching standard for paramedic intubation and a common individual paramedic skills log by July 2015, alongside annual re-assessment of advanced … (AI summary)
Responded
Liam Coleman
Concerns: There were insufficient ambulances available to cover the number of Red 1 and Red 2 calls during the early hours of 3rd October 2012.
Overdue
Thomas Maher
Concerns: Concerns included missing medical records, inconsistent falls risk assessments, and an inactive fall alarm during a patient's fall. The coroner also identified difficulties with inter-hospital patient transfers and incompatible electronic and paper patient record systems.
Response (Central Manchester University Hospital NHS Trust): • The Trust implemented a new process for scanning records of deceased patients and high-level incidents into the electronic patient record system, with a long-term aim for all patient records … (AI summary)
Responded
Anthony Offord
Concerns: Concerns include a lack of training for emergency medical dispatch staff on respiratory difficulty signs and the absence of a requirement to inform managers of unilateral crew stand-offs. Additionally, there is no system to automatically consider all alternative support methods during stand-offs.
Response (Yorkshire Ambulance Service NHs Trust): • The Trust described its robust training program for Emergency Medical Dispatch staff, which includes specific training on breathing difficulties. • The Trust is implementing the Joint Decision Model (JDM) … (AI summary)
Overdue
Rosalind Adshead
Concerns: Concerns were raised regarding the unsafe transfer of a severely ill patient between hospitals in the early hours of the morning, with the coroner noting that ambulance shortages during the day should not be a valid excuse for such timing.
Overdue
William Davies
Concerns: The coroner identified confusion within the prison regarding the process for requesting an ambulance for life-threatening situations and the procedures for attending such prisoners. Concerns were also raised that the GP lead was unaware of her authority to verify death.
Response (Care UK): • Control Room staff were re-briefed on the requirement to call an ambulance during a level 1 emergency, and a crib sheet was developed for London Ambulance Service information. • … (AI summary)
Responded
David Ince
Concerns: The coroner noted that ECG information and traces from ambulance staff were not consistently recorded in A&E notes or routinely handed over to hospital staff upon patient arrival.
Overdue
Elizabeth Leah
Concerns: The coroner raised concerns about an elderly patient with a broken leg being advised to take a taxi to hospital due to ambulance resource shortages. Insufficient ambulances and staff, exacerbated by A&E delays and bed blocking, were noted as issues requiring central government action.
Response (Department of Health): • NWAS increased staffing levels in control rooms and for road staff. • NWAS introduced Advanced Community Paramedics and expanded the use of volunteer services and Community First Responders. • … (AI summary)
Responded
Sabrina Stevenson
Concerns: The coroner noted worsening ambulance response times, a significant staffing shortfall, and a lack of clear plans to address these issues. Concerns also include gaps in training for pregnancy assessment and patient extraction, and the non-implementation of suggested system improvements.
Response (College of Paramedics): • The College of Paramedics established an expert paramedic group. • This group will contribute to guidance on paramedic clinical practice for the profession. (AI summary)
Response (London Ambulance Service): • London Ambulance Service (LAS) outlined plans for significant investment, recruitment of 850 staff, and updates to its operating plan to address response times and staffing. • LAS described updates … (AI summary)
Response (NHS England1): • NHS England, Brent CCG, and the NHS Trust Development Agency conducted weekly operational performance reviews and commissioned a diagnostic review of underperformance. • An external clinical review of the … (AI summary)
Responded
Noel Jones
Concerns: The coroner noted a delay in Mr Jones's acceptance by Worcestershire Royal Hospital likely impacted his survival. The hospital also lacked out-of-hours services for vascular surgery and interventional radiology.
Response (Worcestershire NHS Trust): • The Trust confirmed it had reviewed its processes for out-of-hours or on-call arrangements for vascular surgery or interventional radiology for critically ill patients requiring transfer. (AI summary)
Responded
Diana Hughes
Concerns: The coroner raised concerns regarding the communication of 'special instructions' during a surgical procedure to other medical personnel, specifically via the WHO/Surgical checklist.
Response (Gloucestershire Hospitals NHS Trust): • The Trust is considering amending the WHO/Surgical checklist to include an instruction for staff to check whether special post-operative instructions have been physically written on the operation note. • … (AI summary)
Responded
Barbara Patterson
Concerns: The Pathways system fails to prompt CPR advice for agonal breathing, a known fault Pathways has not amended. There were also delays in ambulance dispatch and arrival, partly due to paramedic shortages and hospital handover delays.
Response (Department of Health): • The NHS Pathways system is subject to ongoing review and updates, with amendments made to supporting information on breathing assessment. • The North East Ambulance Service has reduced its … (AI summary)
Response (CQC): • The CQC was monitoring an action plan submitted by North East Ambulance Service (NEAS) following previous inspections in February 2014 where non-compliance was identified. • The CQC intends to … (AI summary)
Response (North East Ambulance Service NHS Trust): • The Trust had conducted an investigation into the issues raised. • The Trust had provided management evidence regarding the issues. (AI summary)
Responded
George Boulton
Concerns: The coroner identified insufficient escalation protocols for suspected stroke patients across primary care, bed bureau, and ambulance services, leading to delays in emergency response and risking timely diagnosis and treatment options.
Response: • East Midlands Ambulance Service will discuss workforce changes required to implement the Advanced Medical Priority Dispatch System for GP and Health Care Professional urgent calls, and will communicate to … (AI summary)
Overdue
Colin Moulton
Concerns: Critical information from a paramedic's verbal handover to an A&E triage nurse was lost. Additionally, the Ambulance Trust did not notify the Hospital Trust of their presence within the hospital grounds while searching for the individual, which could have aided communication.
Response (Department of Health): • The Department of Health noted that Fairfield General Hospital had implemented improved handover procedures between paramedics and A&E staff. • The Department of Health stated that all ambulance trusts … (AI summary)
Overdue
David Sweeney
Concerns: The coroner noted that a call regarding an unconscious man did not receive red prioritisation, raising concerns about a potential pattern in the London Ambulance Service's handling of calls for unconscious patients.
Overdue
John Robinson
Concerns: The coroner raised concerns regarding the availability of psychiatric beds on Dovedale, as Mr Robinson required a bed but none were available before his condition deteriorated.
Overdue
Kala Skinner
Concerns: The coroner identified issues with a Clinical Advisor's assessment and advice, as well as insufficient welfare calls. Concerns were also raised about the adequacy of training, competency assessment, and auditing for Clinical Advisors, noting a lack of a safety net for identifying risks.
Overdue
Ronald Bonfield
Concerns: The coroner noted a lack of uniform practices across GP surgeries for monitoring District Nurse Teams' compliance with delegated INR testing, posing a risk of unmonitored over-anticoagulation. Without action, there remains a risk of future deaths in similar circumstances.
Overdue
Adil Habib
Response (HM Prison and Probation Service): • A DVD and accompanying training material on the safe use of force and medical complications of restraint have been completed. • The DVD includes medical advice on safe restraint … (AI summary)
Response (London Ambulance Service NHS Trust): • The London Ambulance Service (LAS) added the Roman Way gate address for HMP Pentonville to its Gazetteer with GPS information. • The LAS obtained a list of postal addresses … (AI summary)
Responded
Stuart Knight
Concerns: Significant delays occurred in despatching an ambulance to an unconscious patient who had clearly suffered a serious head injury.
Response (East Midlands Ambulance Service): • The service has invested in staff and vehicle resources, including recruitment, training, and fleet expansion since 2014. • It introduced the Paramedic Pathfinder tool, with 94% of staff trained … (AI summary)
Responded
Mrs Withers
Concerns: The coroner raised concerns about ambulance service policies on obtaining and saving patient medical history, call-back procedures for unresponsive patients, and staff abstraction levels. Further issues were noted regarding time loss during ambulance handovers to hospital A&E.
Overdue
Christopher Connor
Concerns: The coroner noted concerns regarding the ambulance's delayed arrival, which only occurred after police intervention was needed to expedite the call.
Response (Welsh Ambulance Service NHS Trust): • The Trust undertook an investigation into the delayed ambulance response. • The Trust addressed the failings identified in the Clinical Contact Centre allocator in line with its policies and … (AI summary)
Responded
Madhumita Mandal
Concerns: The coroner identified issues with Croydon University Hospital's urgent care streaming model, where a receptionist without medical training conducted initial assessments, delaying critical care. This raises questions about the appropriate qualification level for patient assessment and lessons for other Trusts.
Response (MMandal Response1): • The Vitalpac Early Warning Score (VIEWS) protocol was implemented in September 2013, including full observations by a Healthcare Assistant within 20 minutes of arrival. • Interim changes introduced in … (AI summary)
Response (MMandal Response2): • The streaming model between the Urgent Care Centre and the emergency department is now delivered by senior emergency department nurses. • The handover process from the Urgent Care Centre … (AI summary)
Response (MMandal Response3): • The streaming model was modified in November 2013 to include basic observations by a Healthcare Assistant for patients streamed to the Urgent Care Centre, with scores used to identify … (AI summary)
Responded
Matthew Crowley
Concerns: The coroner identified delays in A&E assessment due to staffing and an inoperable protocol. Concerns also included on-call consultants lacking updated patient deterioration information, leading to delayed decisions and issues with transfer communication.
Overdue
Mandeep Singh
Concerns: The coroner noted severe demand and staff shortages within the North East Ambulance Service division contributed to ambulance arrival delays, further impacted by road closures and diversions.
Response (North East Ambulance Service): • The Trust has implemented initiatives to manage demand, including public education campaigns and a trial scheme with Fire and Rescue Services for Emergency Medical Responders. • The Trust has … (AI summary)
Responded
Monica Lewis-Hinds
Concerns: The London Ambulance Service's call triage protocol does not require call handlers to explicitly ask about the "type of fit," only completing the section if the caller offers the information, which the coroner suggests may need amendment.
Overdue
Luke Ayres
Concerns: The coroner noted that ward staff did not directly call 999, risking call disconnections during transfers, and that staff providing information to ambulance services might lack up-to-date patient status. Additionally, there was no one immediately available to escort paramedics upon their arrival at reception, causing delay.
Response (Birmingham and Solihull NHS Trust): • The Trust approved funding to replace the aged telephony system at Reaside Clinic, with work anticipated to commence in Quarter 3 of 2016. • The Trust decided to extend … (AI summary)
Responded
Carl Thompson
Concerns: The coroner identified issues with life-saving equipment, including a lack of suction equipment, a defective ambubag, and an inoperable defibrillator. There were also substantial delays in the arrival of emergency ambulances.
Overdue
Ronald Hamer
Concerns: The coroner noted an ambulance response time of nearly 2 hours and 40 minutes for an Amber 2 call, significantly exceeding the 20-minute target. Concerns were raised about the lack of communication with the patient's family and insufficient planning for maintaining services during periods of high call volume.
Response (Welsh Ambulance Service NHS Trust): • The Trust developed an Action Plan in response to the Regulation 28 report. • Actions for improvement are being monitored by a Task and Finish Group and scrutinised by … (AI summary)
Overdue
Mia Gibson
Concerns: The coroner identified an over-reliance on maternal observations in obstetric emergencies, potentially overlooking fetal distress, and noted significant ambulance resource delays due to meal break management and lack of 'open mic' reports.
Overdue
Peter Scott
Concerns: The coroner raised concerns about the ambulance service's significant resource issues, where demand consistently exceeds available capacity, requiring frequent activation of capacity management plans. Delayed patient handovers at hospitals further impact ambulance availability.
Response (East Midlands Ambulance Service): • East Midlands Ambulance Service (EMAS) and commissioners agreed to conduct an independent strategic demand, capacity, and price review for the 2016/17 contract and to implement its outcomes. • EMAS … (AI summary)
Response (Hardwick CCG): • Hardwick CCG committed to undertaking a jointly commissioned external strategic review of ambulance service capacity and demand. • Commissioners provided additional funding to East Midlands Ambulance Service (EMAS) to … (AI summary)
Response (NHS England): • Commissioners committed to jointly undertaking an external strategic review of capacity and demand with EMAS. • Additional funding was provided to EMAS in the 2016/17 contract settlement to increase … (AI summary)
Response (NHS Improvment): • NHS Improvement stated it was working with the East Midlands Ambulance Service NHS Trust and partner organisations to address resourcing and improve response times. • The trust conducted a … (AI summary)
Overdue
Valerie Ellis
Concerns: The coroner noted insufficient discharge counselling for a patient on Apixaban, concerns about 111 advisor training and algorithm imprecision, and a breakdown in IC24 callback procedures. A joint Root Cause Analysis has not yet occurred.
Response (South East Coast Ambulance Service NHS Trust): • The Trust detailed the NHS Pathways training provided to 111 health advisors, including core modules, common learning, shadow shifts, and supervised live support, and confirmed 3 hours of face-to-face … (AI summary)
Response (Western Sussex Hospital NHS Trust): • The Trust launched a NOAC alert card and introduced a Standard Operating Procedure for pharmacy staff, supported by daily electronic prescribing reminders. • Discussions have been initiated with NHS … (AI summary)
Response (Integrated Care 24 Limited): • Integrated Care 24 Limited introduced new Failed Contact Guidance and a new software version to prevent premature call closure. • The organisation reviewed its induction training programme to include … (AI summary)
Responded
Joyce Ravenhill
Concerns: The coroner noted a lack of operational policy or facility for triage nurses to effectively communicate the need for an urgent doctor's appointment when information was automatically electronically generated.
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) applied a procedure for staff to manually note when an appointment booking was attempted but not possible. • East Cheshire NHS Trust (ECT) issued … (AI summary)
Responded
Pamela Conway
Concerns: The coroner raises concerns regarding ongoing unacceptable delays for patients waiting in ambulances, which also makes ambulance resources unavailable. Additionally, patient flow problems persist within Maelor Hospital's Emergency Department.
Response: • The Health Board has enclosed two working action plans. • The action plans will be scrutinised by the Assistant Director of Nursing and the Hospital Medical Director. • The … (AI summary)
Responded
Kyles Lowes
Concerns: The coroner raised concerns about extended emergency care journey times from Berwick-upon-Tweed and the risks posed by having only one paramedic crew after 10 p.m., especially when the crew is unavailable due to breaks or out-of-area duties.
Response (Northumberland Clinical Commissioning Group): • The Clinical Commissioning Group (CCG) increased overall expenditure on ambulance services and committed to supporting the North East Ambulance Service's (NEAS) transformation programme. • The CCG commissioned the national … (AI summary)
Overdue
Joshua Smith
Concerns: The coroner identified deficiencies in the emergency response, including a delay in immediately alerting police, difficulties in identifying the caller's location, and a lack of clear command, control, and coordination, noting that JESIP was not followed.
Response (Maritime Coastguard Agency): • The agency reviewed its systems, issued updated guidance, and modified training packages. • All Coastguard tactical commanders attend JESIP courses, and strategic level commanders attend Multi-Agency 'Gold' courses. • … (AI summary)
Response (Northumberland Fire and Rescue Service): • Northumberland Fire and Rescue Service (NFRS) confirmed and reaffirmed internal procedures for 999 call handling, including dual monitoring and immediate review for missing persons calls. • NFRS reviewed its … (AI summary)
Response (Northumbria Police): • A multi-agency meeting and formal debrief were conducted to discuss the concerns identified in the report. • A specific THRIVE training program for North East Ambulance Service (NEAS) call … (AI summary)
Overdue
Brian Mills
Concerns: The coroner noted consistently high levels of outstanding emergency calls and waiting times that exceeded the service's target response times, posing a risk to future deaths.
Response (East of England Ambulance Service NHS Trust): • The Trust has introduced initiatives including increasing clinicians in Emergency Operations Centres and a process to release ambulance crews from hospital queues. • The Trust is negotiating with regulators … (AI summary)
Responded
Mary Muldowney
Concerns: The coroner raised concerns that Ms Muldowney was refused urgent transfer to a neurosurgical unit due to a lack of intensive care beds, despite the time-critical nature of her required surgery.
Overdue
Dipa Lad
Concerns: Concerns are raised about EMAS's local protocol allowing staff to deem resuscitation 'futile' without clear guidance, a deviation from national standards. There is also insufficient staff awareness and training on this significant protocol change.
Response (East Midlands Ambulance Service NHS Trust): • The 'Diagnosis of Death Procedure' was reviewed, revised, and approved to align with national guidance and include specific information on determining futility. • A revised procedure for disseminating clinical … (AI summary)
Responded
Christopher MacMorland
Concerns: The coroner noted concerns that Mr MacMorland was not transferred to a specialist gastroenterology ward despite five consultant requests, potentially affecting his outcome. It was also noted that consultants' requests for patient transfer to specialist wards are commonly not implemented.
Response (Portsmouth Hospitals NHS Trust): • The Hospital has implemented a 'buddy' ward system. • This system ensures patients of a specific specialty are cohorted into appropriate specialist or designated buddy wards. • Consultants' patients … (AI summary)
Responded
Select committee recommendations(12)
#21 —
Recommendation: As part of its broader health and care recovery plan, the Government must produce an independently-verified analysis of how many, and what type, of extra beds the NHS needs in order to provide safe and effective everyday care for patients, …
Response attribution not verified
#20 —
Recommendation: An NHS running too ‘hot’ for patients to move from crowded emergency departments into wards cannot provide safe, efficient or effective care in the long- term. Furthermore, the advent of ICSs offers an opportunity to provide patients with more integrated …
Response attribution not verified
#15 — Significant regional disparities in ambulance response times, particularly impacting rural services.
Recommendation: In 2021–22, mean Category 1 ambulance response times varied from six minutes 51 seconds for the London ambulance service to ten minutes 20 seconds for the South-West ambulance service, and average 999 call response times ranged from 5.4 seconds for …
Response attribution not verified
#3 — Clearly set out causes of urgent care performance variation and initiatives to improve standards.
Recommendation: The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. …
Response attribution not verified
#26 —
Recommendation: Historically, accident and emergency departments have been over-stretched, over- burdened and running over capacity. We have heard that the initial decline in patient attendances at A&E departments during the pandemic to some extent “cured” the problem of “corridor care”. However, …
Response attribution not verified
#18 — Interdependency of urgent and emergency care services creates system-wide bottlenecks from issues.
Recommendation: The different services for urgent and emergency care are highly connected and interdependent, meaning that issues in one service impacts throughout the rest of the system.46 If the NHS is unable to discharge patients from hospitals when they no longer …
Response attribution not verified
#10 — Department's oversight of NHS England's A&E performance targets remains ineffective and unachieved.
Recommendation: We raised concerns over the effectiveness of the Department’s oversight of NHS England’s performance against its targets, including the A&E target for 95% of patients to be admitted, transferred, or discharged within four hours.23 This target has not been achieved …
Response attribution not verified
#4 — Set out actions to address delayed discharges caused by hospital, community, and social care constraints.
Recommendation: Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn …
Response attribution not verified
#7 —
Recommendation: We are concerned ICSs may struggle to make progress on their longer-term aims to prevent ill-health, given pressure for progress on immediate national priorities, for example, the need to reduce elective care backlogs and bring down A&E and ambulance waiting …
Response attribution not verified
#14 — Significant, persistent regional variations in patient experience and service performance across NHS.
Recommendation: We and past Committees have repeatedly expressed concerns about variations in patients’ experience of health and care.32 The C&AG’s report highlighted considerable differences in both service performance and access across geographical areas and providers. Proportions of the most serious A&E …
Response attribution not verified
#1 — Evidence taken from DHSC and NHS England on access to unplanned or urgent care.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) and NHS England about access to unplanned or urgent care.1
Response attribution not verified
#12 — Short-term hospital discharge funding shows positive impact but avoids systemic issues.
Recommendation: With regard to additional funding for hospital discharge—£600 million in 2023– 24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in …
Response attribution not verified
HSSIB safety recommendations(6)
Transfer of critically ill adults
It is recommended that the Association of Ambulance Chief Executives should work with partners to define best practice standards for the criteria, format, delivery and receipt of ambulance service pre-alerts.
Safety Recommendation
Emergency response to heart attack
HSIB recommends that NHS England and NHS Improvement support the Joint Ambulance Improvement Programme to respond to emerging risks and research highlighting factors impacting on effective ambulance response.
Safety Recommendation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
It may be beneficial for the clinical commissioning group to provide oversight of stroke pathways until a hyper-acute stroke unit is established, to ensure that there is a clearly understood pathway for FAST-positive patients between 23:00 hours and 08:00 hours. …
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services
HSSIB recommends that NHS England/Department of Health and Social Care reviews and amends the service specification for primary percutaneous coronary intervention (PPCI) centres, to include a requirement for a function enabling two-way communication with ambulance crews for shared decision making …
Safety Recommendation
12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — …
HSSIB recommends that NHS England/Department of Health and Social Care reviews and amends the service specification for primary percutaneous coronary intervention (PPCI) centres, to include a requirement for a function enabling two-way communication with ambulance crews for shared decision making …
Safety Recommendation
Emergency response to heart attack
HSIB recommends that NHS England and NHS Improvement revise the Ambulance Clinical Quality Indicator: Clinical Outcomes for ST-elevation myocardial infarction to reflect each element of the call to balloon response and review this indicator alongside the critical time standards workstream.
Safety Recommendation
CQC inspection actions(22)
The Princess Royal Hospital
The trust must ensure patients can access care and treatment in a timely way. This includes ambulance handover times and patient waiting times for treatment and arrangements to admit, treat and discharge patients.
Must Do
Russells Hall Hospital
The trust must ensure they continue their work to improve ambulance handovers and patient flow within the department.
Must Do
Royal Shrewsbury Hospital
The trust must ensure patients can access care and treatment in a timely way. This includes ambulance handover times and patient waiting times for treatment and arrangements to admit, treat and discharge patients.
Must Do
Royal Hallamshire Hospital
The trust must ensure that ambulance handovers are completed within 15 minutes in line with guidance.
Must Do
Pilgrim Hospital
The service must ensure the trust standard operating procedure for management of reducing ambulance delays is fully implemented. Patients waiting on ambulances should be reviewed by medical staff within an hour and within 30 minutes where the national early warning …
Must Do
Pilgrim Hospital
The trust must ensure the trust standard operating procedure for management of reducing ambulance delays is fully implemented.
Must Do
Northern General Hospital
The trust must ensure that ambulance handovers are completed within 15 minutes in line with guidance.
Must Do
Kidderminster Hospital and Treatment Centre
The trust must ensure that ambulance handovers are timely and effective and that all patients are assessed in a timely manner. The trust must ensure that patients receive medical and speciality reviews in a timely manner.
Must Do
Royal Sussex County Hospital
The trust should should ensure that ambulance crews can handover their patients as soon as possible so that they can be released to respond to further emergency calls.
Should Do
North Tyneside General Hospital
The trust should continue to work to improve time to initial assessment and ambulance handover times.
Should Do
Bridgwater Community Hospital
The service must ensure there are effective processes for amending the home birth and midwifery-led unit provision at times of increased demand on ambulance services to ensure timely transfer to the obstetric-led maternity unit is not delayed.
Must Do
Berwick Infirmary
The trust should continue to work to improve time to initial assessment and ambulance handover times.
Should Do
Berwick Infirmary
The department must continue to monitor flow and work towards improving flow through the department especially at times of surge.
Must Do
Alnwick Infirmary
The trust should continue to work to improve time to initial assessment and ambulance handover times.
Should Do
Royal Hallamshire Hospital
The trust must improve patient waiting times in the Accident and Emergency department.
Must Do
Royal Hallamshire Hospital
The trust must implement an effective system to ensure all patients waiting to be admitted to the department from the ambulance queue are monitored for signs of deterioration.
Must Do
Northern General Hospital
The trust must improve patient waiting times in the Accident and Emergency department.
Must Do
Northern General Hospital
The trust must implement an effective system to ensure all patients waiting to be admitted to the department from the ambulance queue are monitored for signs of deterioration.
Must Do
Bridlington Hospital
The service must ensure they continue to work to improve the following performance standards for its urgent and emergency care service at Scarborough hospital: ▪ the median time from arrival to treatment. ▪ the percentage of patients admitted, transferred or …
Must Do
Broomfield Hospital
The trust should consider how to improve the average time patients wait for treatment in the emergency department and the overall time patients are in the department before they are discharged or accepted into the hospital as an inpatient.
Should Do
Fairfield General Hospital
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access the service when they need it.
Must Do
Fairfield General Hospital
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access the service when they need it.
Must Do
PPO death in custody recommendations(6)
The Governor
The Governor should ensure that there are no delays in ambulances entering and leaving the prison; and that in a medical emergency, access from the prison gate to the wing is coordinated to allow paramedics to reach an incident quickly.
The Governor
The Governor should review the local Emergency Call Out Protocol 2018 and ensure that there are no unnecessary delays in admitting and discharging ambulances.
The Director and Head of Healthcare
staff facilitate the access of ambulances and paramedics through the prison gate to ensure there are no unnecessary delays.
The Prison Group Director and Governor
The Prison Group Director and Governor should examine in detail their processes for acquiring an urgent ambulance, in conjunction with their partners in the local ambulance service.
The Governor
The Governor should ensure that control room staff call for an ambulance immediately when a medical emergency code is called.
NHS England and SECAmb
NHS England and SECAmb should conduct an investigation into the circumstances surrounding Mr Dawes-Clarke’s resuscitation, including the actions of paramedics in attendance.
IOPC learning recommendations(4)
Investigation into a complaint about contact with a woman prior to her …
The IOPC recommends that the North West Ambulance Service (NWAS), Greater Manchester Police (GMP), Cumbria Constabulary, Cheshire Constabulary, Merseyside Police, and Lancashire Constabulary finalise, agree, and implement the Joint Operating Protocol (JOP) as soon as practicable. Each agency should take …
Investigation into police contact with a man following a report into his …
The IOPC recommends that Merseyside Police ensures that there is a robust agreement in place between the force and North West Ambulance Service NHS Trust in relation to people who come into contact with the police and require urgent medical …
Recommendations - Sussex Police, November 2023
The IOPC recommends that Sussex Police develop an escalation process to be adopted in the event that a call has been passed to the Ambulance Service but the Ambulance Service is unable to resource the call. This process should be …
Recommendation - Bedfordshire Police, November 2020
The IOPC recommends that Bedfordshire Police implement a robust protocol with the ambulance service that addresses the transportation of vulnerable people, who have not been arrested or formally detained, and require transportation for mental health support.
IMB annual reports(2)
East Sutton Park (2022)
This report for HMP East Sutton Park covers the period from November 2021 to October 2022. The Board finds the open women's prison to be largely safe and well-run, with good staff-resident relationships and effective resettlement efforts, particularly in securing external employment. Key concerns include the low population numbers hindering full use of capacity, residents arriving with insufficient time for resettlement, and the need to review fire evacuation procedures.
PRISON
Key concerns
Gatwick, Stansted, Luton and Lunar House (2022)
The IMB report for Gatwick, Stansted, Luton airports and Lunar House covers the period ending January 2022, noting a significant increase in detained individuals. While C&C officers are generally compassionate, the Board highlights ongoing concerns about the inadequacy of holding rooms at all locations for increasing numbers, extended stays, and vulnerable individuals. Key issues include limited space, lack of natural light, absence of showers, and persistent problems with access to onsite healthcare professionals and timely medication.
PRISON
Key concerns
IMB individual recommendations(2)
Heathrow Immigration Removal Centre (2021)
The healthcare provider should review the high level of ambulance call outs given they have a 24/7 fully-serviced medical suite on site.
NHS / Healthcare Provider
Hewell (2022)
Healthcare contracts should be reviewed to ensure that there is safe out-of-hours cover; this will improve the health, safety and wellbeing of prisoners, reduce the number of staff hours needed to escort men to outside provision, and reduce the pressure on already overstretched ambulance and NHS resources.
NHS / Healthcare Provider
Noted
Independent reviews(2)
Wessely Review — Rec 125
Ambulance services should establish formal standards for responses to section 136 conveyances and all other mental health crisis calls and ambulance commissioners and ambulance trusts should improve the ambulance fleet, including commissioning bespoke mental health vehicles.
Health & Social Care
Accepted
Darzi Review — Rec 8
A&E is in an awful state. There are three types of A&E department. Type 1 are what most people think of as A&E — they are major departments and able to deal with the full range of emergencies. Type 2 are for specific conditions such as dental or ophthalmology and …
Health & Social Care
PHSO casework decisions(67)
P-002850 — East Midlands Ambulance Service NHS Trust
Mrs P complained a GP prescribed inappropriate medication and failed to identify infection. She also alleged a six-hour delay in her father's hospital handover and treatment, contributing to his death.
NHS in England
Upheld
Aug 2024
P-003279 — Torbay and South Devon NHS Foundation Trust
Mrs L complained about a 13-hour ambulance wait for her mother, delayed admission, failure to perform an endoscopy, and that an injection may have hastened her mother's death.
NHS in England
Partly Upheld
Jan 2025
P-002890 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
A patient complained about poor A&E care for sepsis, including being on a trolley without bedding, unmonitored fluids, untimely treatment, and insufficient food, drink, and pain relief.
NHS in England
Aug 2024
P-003534 — North West Ambulance Service NHS Trust
Mrs J complained about a long ambulance waiting time (1 hour 45 minutes) for her seriously ill husband, which she believes delayed treatment and contributed to his death.
NHS in England
May 2025
P-003752 — A practice in the East Riding of Yorkshire …
Mr A complained about a seven-hour ambulance delay and a GP practice's failure to review medication, which he believed contributed to his wife's stroke and death.
NHS in England
Jul 2025
P-004024 — South Western Ambulance Service NHS Foundation Trust
The Trust incorrectly categorised 999 calls and delayed sending an ambulance for her husband, which Mrs L believes caused irreparable heart damage and his subsequent death.
NHS in England
Sep 2025
P-004654 — South Western Ambulance Service NHS Foundation Trust
The ambulance service delayed sending an ambulance, prevented a rapid response vehicle from attending, and failed to understand the seriousness of her son's breathing difficulties, leading to his death.
NHS in England
Partly Upheld
Jan 2026
P-001544 — University Hospitals Of Leicester NHS Trust
Mrs R complained about ambulance service delays and the Trust's failure to diagnose and treat neck fractures until 29 June, causing prolonged pain and distress.
NHS in England
Sep 2022
P-002374 — London Ambulance Service NHS Trust
Mrs I complained about a three-hour ambulance delay for her father's stroke symptoms. She alleged this caused him to miss vital treatment, resulting in severe paralysis, aphasia, and memory loss.
NHS in England
Dec 2023
P-002603 — East of England Ambulance Service NHS Trust
Mrs L complained the ambulance service gave incorrect advice about her husband's care, delaying treatment for a suspected heart attack, and other trusts missed diagnoses.
NHS in England
May 2024
P-003125 — Wirral University Teaching Hospital NHS Foundation Trust
Complaints across NWAS, the Trust, and a Practice regarding delayed ambulance, care outcomes, complaint handling, and organisational planning, impacting Mrs W's care.
NHS in England
Nov 2024
P-003241 — University Hospitals of Leicester NHS Trust
Mr E complained his wife experienced delayed emergency admission, poor care, neglect leading to pressure sores, and an MRI scan issue at two Trusts, causing her distress before death.
NHS in England
Dec 2024
P-003239 — North West Ambulance Service NHS Trust
Mrs L complained NWAS left her mother on a trolley for over 30 hours without adequate care, moved her with a fractured pelvis, and the Trust failed to monitor falls risk, leading to a fall.
NHS in England
Dec 2024
P-003275 — North East Ambulance Service NHS Foundation Trust
Mrs G complained the Trust took too long to get her husband into an ambulance because the first ambulance lacked appropriate equipment, believing faster transport might have saved his life.
NHS in England
Jan 2025
P-003319 — North West Ambulance Service NHS Trust
Mr O complained a paramedic failed to recognise his father, Mr W, needed urgent treatment, causing a 14-hour ambulance delay. He believes this delay led to his father's death from pneumonia.
NHS in England
Feb 2025
P-003504 — Yorkshire Ambulance Service NHS Trust
Mr S complained an 11-minute ambulance delay during his partner's catastrophic asthma attack caused her death, which he believed was avoidable.
NHS in England
Apr 2025
P-003657 — East Kent Hospitals University NHS Foundation Trust
Mr P complained of delayed treatment and handover by the ambulance service, and delayed admission and family notification by the hospital Trust, contributing to his father's death.
NHS in England
Partly Upheld
Jul 2025
P-004019 — Yorkshire Ambulance Service NHS Trust
Miss A complained about delays in an ambulance reaching her father during a heart attack, leading to his death. She also complained about the Trust's delayed and mishandled complaint response.
NHS in England
Not Upheld
Sep 2025
P-003944 — Bradford Teaching Hospitals NHS Foundation Trust
Mrs P complained the Ambulance Trust and Trust ignored concerns about her son's blocked shunts, misdiagnosed him, delayed diagnosis and treatment, and delayed his transfer, leading to his death.
NHS in England
Sep 2025
P-004036 — West Midlands Ambulance Service University NHS Foundation Trust
Miss N complained it took six hours for an ambulance to arrive for her brother, who was struggling to breathe, and the service failed to call back. She believed earlier arrival could have prevented his death.
NHS in England
Sep 2025
P-004246 — South East Coast Ambulance Service NHS Foundation Trust
The Trust's call handler incorrectly triaged her aunt's 999 stroke calls, delaying ambulance dispatch and transport to a specialist hospital, leading to permanent disability.
NHS in England
Oct 2025
P-004441 — West Midlands Ambulance Service University NHS Foundation Trust
Mr Y complained about a thirteen-hour ambulance delay and the ambulance crew's failure to optimize his mother's low oxygen levels, believing it contributed to her death.
NHS in England
Partly Upheld
Dec 2025
P-004542 — South East Coast Ambulance Service NHS Foundation Trust
Mrs F complained paramedics failed to take her to hospital and communicated poorly, leading to a perforated appendix and multiple abscesses.
NHS in England
Dec 2025
P-004709 — Manchester University NHS Foundation Trust
Miss X complained about ambulance delays and a hospital's delay in transferring her father for life-saving surgery, believing these contributed to his internal bleed, organ failure, and death.
NHS in England
Partly Upheld
Jan 2026
P-004687 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust delayed investigations into her son's gastrointestinal bleeding, lacked staff, delayed transfer, and provided inconsistent complaint responses, contributing to his death.
NHS in England
Not Upheld
Jan 2026
P-001581 — North East Ambulance Service NHS Foundation Trust
The complainant alleged ambulance operators incorrectly prioritised his son's spinal injury, causing a two-hour delay in ambulance arrival and potentially worsening his condition.
NHS in England
Oct 2022
P-001937 — London Ambulance Service NHS Trust
Mr X complained the ambulance arrived too late for his brother, who subsequently died, alleging the Trust should have sent help sooner.
NHS in England
Apr 2023
P-002281 — North West Ambulance Service NHS Trust
Mr U complained the Trust repeatedly failed to transport his mother to hospital due to poor risk assessments. He alleged this caused her pain, deterioration, mental distress, and contributed to her death.
NHS in England
Nov 2023
P-002601 — South Central Ambulance Service NHS Foundation Trust
Mrs T complained the Ambulance Service delayed and mishandled her father's emergency call, causing a slow ambulance arrival and resulting in him dying alone.
NHS in England
May 2024
P-002649 — Barts Health NHS Trust
Miss E complained about her son's care, including delayed admission, missed medication, unattended drip alarms, an overly long MRI, and inadequate discharge planning and equipment.
NHS in England
May 2024
P-002805 — East of England Ambulance Service NHS Trust
Mr G complained about multiple missed opportunities to diagnose heart problems, including an unacted-on X-ray and a failed ambulance attendance, leading to a delayed heart failure diagnosis.
NHS in England
Jul 2024
P-002882 — West Midlands Ambulance Service University NHS Foundation Trust
Mrs M complained her mother suffered a leg injury during ambulance transfer due to care failings, which she believed contributed to her mother's premature death.
NHS in England
Aug 2024
P-002889 — Yorkshire Ambulance Service NHS Trust
Mr G complained an ambulance crew failed to take his uncle to hospital despite a 999 call handler indicating the need for blood tests, leading to his uncle's death three days later from a blood clot.
NHS in England
Partly Upheld
Aug 2024
P-003283 — South East Coast Ambulance Service NHS Foundation Trust
Mr A complained about severe NHS 111 call back delays and inadequate observations/communication by ambulance crews regarding his partner's condition, contributing to her unexpected death.
NHS in England
Jan 2025
P-003405 — Royal United Hospitals Bath NHS Foundation Trust
Miss A complained ambulance staff failed to record her father's head pain after a fall, and hospital staff failed to act on head trauma or obtain imaging, which she believes led to his death.
NHS in England
Mar 2025
P-003560 — Northern Care Alliance NHS Foundation Trust
Mr W complained his father died due to a considerable wait in the Emergency Department before being seen by a consultant, seeking financial compensation.
NHS in England
May 2025
P-003668 — The Royal Wolverhampton NHS Trust
Mrs L complained the Trust failed to follow up on her father's 2020 TAVI clinic appointment and was unprepared for his arrival and deteriorating condition in May 2023, possibly contributing to his death.
NHS in England
Partly Upheld
Jul 2025
P-004135 — A practice in the Worthing area
The Practice failed to manage her father's worsening health, coordinate care, or act on deteriorating kidney function. A treatment centre couldn't accommodate his mobility, and an ambulance was delayed.
NHS in England
Oct 2025
P-004341 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr K complained about delays in Mrs K being seen by a doctor and given appropriate pain relief in ED, missing an opportunity for survival and causing unnecessary suffering.
NHS in England
Partly Upheld
Nov 2025
P-004665 — An independent provider in the City of Derby …
The K's complained 111 and WMAS incorrectly categorised their mother's symptoms, delayed ambulance arrival, and provided incorrect complaint responses, causing distress.
NHS in England
Jan 2026
P-001103 — East of England Ambulance Service NHS Trust
Mr R complained the Ambulance Trust delayed his wife's ambulance for over four hours, contributing to her death, and also alleged hospital care failings.
NHS in England
Not Upheld
Aug 2021
P-003859 — East of England Ambulance Service NHS Trust
The Trust refused to take her severely ill father to hospital in April 2021, causing his death from preventable sepsis.
NHS in England
Not Upheld
Sep 2023
P-002251 — London Ambulance Service NHS Trust
Mr B complained about severe delays and incorrect categorization of his wife's 999 call, leading to a prolonged ambulance wait and impacting her subsequent hospital treatment.
NHS in England
Oct 2023
P-002289 — North East Ambulance Service NHS Foundation Trust
Mrs A complained the ambulance crew failed to properly assess her condition or take her to hospital, leading to delayed sepsis/meningitis treatment.
NHS in England
Nov 2023
P-002425 — West Hertfordshire Hospitals NHS Trust
Mr T complained West Hertfordshire Hospitals NHS Trust's ED staff did not clean his wounds or provide stitches, causing lasting physical and psychological scars.
NHS in England
Jan 2024
P-002452 — Countess of Chester Hospital NHS Foundation Trust
Mr O complained about excessive waiting times in ED and staff ignoring his concerns, leading to a traumatic and distressing experience.
NHS in England
Feb 2024
P-002732 — ERS Medical
ERS Medical failed to take action when Mrs A didn't answer the door for transport, and didn't notify her daughter or the hospital, leading to Mrs A being on the floor for over 30 hours.
NHS in England
Not Upheld
Jun 2024
P-002974 — A practice in the Cannock Chase area
Mr U complained the Practice sent his father home instead of waiting for an ambulance. He also alleged the Trust delayed an ambulance call-out for a heart attack, contributing to his father's death.
NHS in England
Sep 2024
P-003064 — A practice in the Gloucester area
Dr M complained about a doctor's failure to administer oxygen, delays in requesting an emergency ambulance, and inaccurate oxygen readings for his mother, believing her death was avoidable.
NHS in England
Oct 2024
P-003325 — Imperial College Healthcare NHS Trust
The Practice and Trust allegedly made wrong diagnoses and provided incorrect care for abdominal pain. LAS declined hospital transport, causing prolonged pain and a more invasive operation.
NHS in England
Feb 2025
LGO / SPSO decisions(200)
PSOW-202308584 — Welsh Ambulance Services University NHS Trust
Mrs C complained about the care her late husband, Mr C, received from Welsh Ambulance Services University NHS Trust (“the Trust”) on18 December 2022. The investigation considered whether Mr C was appropriately triaged and prioritised during the first and subsequent calls to 999. It also considered whether sufficient and accurate …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
201102504 — Scottish Ambulance Service
Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201507666 — Scottish Ambulance Service
Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2016
201705035 — Scottish Ambulance Service
Mr C complained on behalf of his wife (Mrs A) that the ambulance service unreasonably failed to dispatch an ambulance following an emergency call and that they did not handle his complaint reasonably. Mrs A had been diagnosed with a tumour at the rear of her brain and was waiting …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2018
201800189 — Scottish Ambulance Service
Mrs C complained on behalf of her father (Mr A) that the ambulance service unreasonably failed to dispatch an emergency ambulance. Mr A collapsed at work with a stroke and two calls were made for an ambulance, which took 50 minutes to arrive. Mrs C felt that the call handler …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201706768 — Scottish Ambulance Service
Mrs C complained that the ambulance service delayed in sending an ambulance to her daughter (Miss A) when Miss A dislocated her knee. The ambulance took almost an hour to arrive, which the ambulance service acknowledged was much longer than they would have expected. They apologised for the delay and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2018
201807508 — Scottish Ambulance Service
Mr C called an ambulance after finding his wife (Mrs A) in a concerning condition. The ambulance took longer to arrive than Mr C felt was reasonable, and he made further calls to the Scottish Ambulance Service (SAS) before it arrived. When Mr C complained to SAS about this, their …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2019
202102737 — Scottish Ambulance Service
C complained about Scottish Ambulance Service (SAS) on behalf of A for whom they hold welfare Power of Attorney. A waited for an ambulance for nearly 21 hours. A has multiple sclerosis (a disease that affects central nervous system), lives in a care home and usually has a catheter (a …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2022
202102932 — Scottish Ambulance Service
C’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2023
202410343 — Scottish Ambulance Service
C complained on behalf of their friend (A), a care home resident. A became unwell and was in a lot of pain. An Out of Hours GP suspected an internal bleed and arranged for an ambulance to be requested. A call was made to Scottish Ambulance Service (SAS) at 20:20, …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2026
NIPSO-17159 — Somerton Nursing Home
An investigation has revealed that a nursing home failed to fully record its observations of a resident's head injury following a fall, and did not call an ambulance to take him to hospital until almost eight hours after the incident.
NIPSO (NI Public Service…
Health & Social Care
Mar 2018
PSOW-202101760 — Welsh Ambulance Services NHS Trust
Mr D complained that following his father, Mr F, having developed signs of a stroke, requiring an urgent 999 call, the Trust took over 3 hours to dispatch an ambulance to him. Mr D was specifically concerned that given the time-critical need for treatment following a suspected stroke, his father’s …
PSOW (Public Services Om…
Health
Not Upheld
Sep 2022
PSOW-202103938 — Welsh Ambulance Services NHS Trust
Mr B complained about the treatment that his wife, Mrs B, received from the Trust after she suffered severe injuries in August 2020, specifically, the use of morphine to treat Mrs B, her transport from the boat she was on to an ambulance, and the accuracy of the complaint response. …
PSOW (Public Services Om…
Health
Sep 2022
PSOW-202200413 — Welsh Ambulance Services NHS Trust
The investigation considered whether the appropriate responders/response vehicles were dispatched to Mr A (who was categorised as Amber 1) in an appropriate timeframe and whether the decision to travel at normal speed to hospital (not using sirens and blue lights) was appropriate. The investigation found that Mr A was correctly …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2022
PSOW-202207867 — Welsh Ambulance Services NHS Trust
Mr W complained that Welsh Ambulance Services NHS Trust had failed to respond to the complaint he submitted in July 2022. The Ombudsman decided that there had been a delay in WAST’s response and this had caused inconvenience and frustration for Mr W. The Ombudsman decided to settle the complaint …
PSOW (Public Services Om…
Health
Mar 2023
PSOW-202105404 — Welsh Ambulance Services NHS Trust
Ms A complained that her late father, Mr B, not being taken to the local hospital by the first ambulance crew adversely affected his treatment and investigation for a suspected stroke. Ms A said that her father’s condition had deteriorated and the following day he was very confused. He had …
PSOW (Public Services Om…
Health
Upheld
Mar 2023
PSOW-202302509 — Welsh Ambulance Services NHS Trust
Ms Z complained about the appropriateness of the categorisation given by Welsh Ambulance Services NHS Trust (“the Trust”) to an emergency call made by her father in August 2022. Ms Z also complained about the appropriateness of a welfare check made by the Trust, specifically whether further questions should have …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202204639 — Welsh Ambulance Services NHS Trust
We investigated a complaint by Mr A about the delay in obtaining an Out of Hours GP visit for his late wife, Mrs A, which was requested via 111. Specifically, we considered whether Mrs A’s symptoms were appropriately assessed by the 111 service, which is provided by the Trust, and …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202202481 — Welsh Ambulance Services NHS Trust
Mrs A complained about Welsh Ambulance Services NHS Trust (“WAST”) and Swansea Bay University Health Board (“the Health Board”). The investigation considered Mrs A’s complaint about the care her late husband, Mr B, received from WAST. Mrs A complained about the delay in an ambulance arriving following her 999 calls …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202309055 — Welsh Ambulance Services NHS Trust
Mrs N explained that she and her family made numerous calls to 999 and the 111 service on behalf of her father, Mr L, throughout 1 January 2023. Mrs N complained that they were advised that the waiting time for an ambulance to attend was 6 8 hours. She said …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202304534 — Welsh Ambulance Services NHS Trust
Mr A complained about the length of time it took an ambulance to arrive after calling 999 and raised concern about information obtained by the Trust’s call takers to determine the call priority. The Ombudsman found the Trust had responded to Mr A’s initial complaint. However, she was concerned to …
PSOW (Public Services Om…
Health
Nov 2023
PSOW-202405127 — Welsh Ambulance Services University NHS Trust
Ms A complained that her father waited over 3 hours for an ambulance to transfer him following a suspected stroke. The call was categorised as an Amber 1 (second highest priority). She said that the Trust’s investigation identified a potential error in the processing of the emergency call. The Ombudsman …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202309682 — Welsh Ambulance Services University NHS Trust
Mrs D complained about the care and treatment provided to her mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”). The investigation considered whether failings in the Trust’s assessment of Mrs C led to delay in her receiving treatment which could have potentially avoided her death …
PSOW (Public Services Om…
Health
Not Upheld
Nov 2024
PSOW-202308948 — Welsh Ambulance Services University NHS Trust
Miss B complained about the care and treatment provided to her late son, Mr C, by Welsh Ambulance Services University NHS Trust (“the Trust”) on 10 and 11 December 2022. Specifically, the handling of the 2x 999 calls made and whether a response should have been dispatched sooner, and if …
PSOW (Public Services Om…
Health
Upheld
Apr 2025
24-001-351b — Southern Central Ambulance Service NHS Foundation Trust (24 …
Summary: Mr A complains the Council caused delays in Mrs B being discharged from hospital because it did not complete its safeguarding enquiries quickly. We will not investigate this complaint further because we found no fault with the actions of the Council.
LGO (Local Government & …
Health
Aug 2024
201405815 — Scottish Ambulance Service
Mr C phoned the Scottish Ambulance Service (the service) for an emergency ambulance as he was suffering from severe abdominal pains. He described his symptoms to one of the service's clinical advisors who told him to attend his local out-of-hours centre. He attended the centre and was examined by a …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2015
201707301 — Scottish Ambulance Service
Mr C complained that the ambulance service failed to send an ambulance to him when he phoned to report that he had suffered a collapse at home. When he received a call back from an ambulance service clinical adviser, Mr C reported that he had suffered flashing lights, neck stiffness, …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2018
201708212 — Scottish Ambulance Service
Mrs C complained about the length of time that her mother (Mrs A) had to wait for an ambulance. We listened to the audio recordings of the relevant phone calls, and we took independent advice from a paramedic adviser. We found that Mrs A's GP surgery had requested that Mrs …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201703342 — Scottish Ambulance Service
Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2018
201800817 — Scottish Ambulance Service
Mrs C complained that the Scottish Ambulance Service (SAS) delayed in sending an ambulance for her husband (Mr A). Mr A's GP requested an ambulance within two hours as Mr A was experiencing vomiting and diarrhoea and was delirious. The ambulance did not arrive until almost eight hours later. SAS …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2019
201809363 — Scottish Ambulance Service
A GP practice contacted the Scottish Ambulance Service (SAS) to request that C's grandchild (A) be transferred from a local hospital to a hospital with a paediatric unit after A became unwell with suspected meningitis. The practice prioritised the request as urgent, therefore requiring a response within an hour. SAS …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
201801934 — Scottish Ambulance Service
Ms C's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
201903349 — Scottish Ambulance Service
Mr A fell at home and a 999 call was made to the Scottish Ambulance Service (SAS) to attend. The call was prioritised as an emergency response where an ambulance would be dispatched as soon as one became available. An ambulance arrived with Mr A approximately four hours after the …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2020
201809644 — Scottish Ambulance Service
C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an emergency ambulance service for their child (A). C expressed concern about the overall time taken for A to be taken to hospital; which was approximately two hours from the original call being made …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
201904012 — Scottish Ambulance Service
C complained on behalf of their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2021
NIPSO-201913310 — Belfast Health and Social Care Trust
We investigated a woman’s complaint that her father did not receive appropriate care in the Emergency Department of the Mater Hospital, Belfast. We found there were failures in his treatment, but that they did not ultimately lead to a deterioration in his health.
NIPSO (NI Public Service…
Health & Social Care
Oct 2021
PSOW-202100520 — Welsh Ambulance Services NHS Trust
Mrs X complained about the ambulance response time and prioritisation assigned to the calls made to the Trust on 9 July 2020. The Ombudsman found that the Trust’s investigation and subsequent Serious Incident Investigation Report had caused Mrs X to raise further questions. The Ombudsman sought and gained the Trust’s …
PSOW (Public Services Om…
Health
Jul 2021
PSOW-202108254 — Welsh Ambulance Services NHS Trust
Ms X complained that WAST had failed to transport her to and from her hospital appointments on various occasions resulting in missed appointments. In considering the complaint the Ombudsman was concerned that there was an issue of a time discrepancy with one of the appointments which WAST had failed to …
PSOW (Public Services Om…
Health
May 2022
PSOW-202102616 — Welsh Ambulance Services NHS Trust
Miss K complained about the delay Mr Q endured on 24 January 2019 waiting for an ambulance. Miss K said that the call was categorised wrongly by Welsh Ambulance Services NHS Trust which resulted in a delay of nearly 4 hours. The Ombudsman’s investigation found that the Trust correctly coded …
PSOW (Public Services Om…
Health
Not Upheld
May 2022
PSOW-202203456 — Welsh Ambulance Services NHS Trust
Mrs A complained about the late arrival of an ambulance, which led to the sad death of her daughter, Mrs B, at her home. She was also concerned about the attitude of the attending paramedic and the Trust’s failure to respond to her concerns about that in its complaint response. …
PSOW (Public Services Om…
Health
Oct 2022
PSOW-202302966 — Welsh Ambulance Services University NHS Trust
Mr B complained about a lack of care and treatment provided to his late mother, Mrs C, by the Welsh Ambulance Services University NHS Trust (“the Trust”) and Swansea Bay University Health Board (“the Health Board”) in September 2022. The Ombudsman’s investigation considered whether the triaging of the emergency calls, …
PSOW (Public Services Om…
Health
Mar 2025
PSOW-202306104 — Welsh Ambulance Services University NHS Trust
Mrs A complained about a lack of care and treatment by the Welsh Ambulance Services University NHS Trust (“the Trust”) for her son, Mr B, on 14 December 2022. The Ombudsman’s investigation considered the handling of 2 999 calls, the standard of record keeping by the attending paramedic, and whether …
PSOW (Public Services Om…
Health
Mar 2025
20-012-668c — West Midlands Ambulance Service NHS Foundation Trust (20 …
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
23-011-466a — East Lancashire Hospitals NHS Trust (23 011 466a)
Summary: Mrs A has complained about a hospital trust and a council in relation to her mother, Mrs B’s discharge to a care home and the fees her mother was charged. We found fault with the Council and the Trust in relation to the discharge a delay in moving Mrs …
LGO (Local Government & …
Health
Upheld
Jul 2024
24-017-682a — London Ambulance Service NHS Trust (24 017 682a)
Summary: Mr X complained about end-of-life care for his mother, Mrs Y, from Jewish Care, Gants Hill Medical Practice, Partnership Of East London Co-Operative, NHS North East London Integrated Care Board and London Ambulance Service NHS Trust. We would likely find fault with the Practice, PELC and ICB if we …
LGO (Local Government & …
Health
Jun 2025
201201695 — Scottish Ambulance Service
Mrs C complained about the treatment that the Scottish Ambulance Service gave to her mother (Mrs A). Mrs A, who suffers from rheumatoid arthritis (an inflammatory disorder that mainly affects the joints), had hurt her leg and was unable to put weight on it. She had been in pain for …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2013
201502258 — Scottish Ambulance Service
Ms C complained on behalf of her father (Mr A) about a delay in transferring him home from hospital. Ms C complained that the ambulance service had not taken reasonable steps to ensure they could transfer Mr A home. The transfer was booked by staff on the hospital ward. They …
SPSO (Scottish Public Se…
Health
Not Upheld
Jan 2016
201601729 — Scottish Ambulance Service
Mrs C's husband (Mr A) suffered a suspected stroke at work. An ambulance was called. Mrs C complained that there was an unreasonable delay in an ambulance attending. She was also unhappy that the caller was not properly informed that there were no ambulances currently available and, later, that there …
SPSO (Scottish Public Se…
Health
Not Upheld
Feb 2017
201804510 — Scottish Ambulance Service
C complained that the Scottish Ambulance Service (SAS) failed to respond reasonably to the request for an ambulance from their late relative (A). C also complained about the way their complaint to SAS about the matter was handled. Through its own investigation, SAS found that the second call from A …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2020
202206802 — Scottish Ambulance Service
C complained about delays in ambulance response time after their elderly parent (A) had a fall at their care home. Care home staff called 999 and, following triage, the call generated an emergency but non-life-threatening response. A clinical triage call took place shortly after followed by another 999 call by …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2024
CQC enforcement actions(3)
Warning Notice: East Suffolk and North Essex NHS Foundation Trust
Inspectors served the trust a warning notice due to concerns about people’s safety and the management of these services. Staff weren’t able to triage everyone arriving at the emergency department within their goal of 15 minutes, and some people waited …
The Ipswich Hospital
Oct 2025
Warning Notice: South East Coast Ambulance Service NHS Foundation Trust
The Care Quality Commission issued a Warning Notice to South East Coast Ambulance Service NHS Foundation Trust, requiring significant improvements in the quality of its services. This action followed a comprehensive inspection in May, which identified six main areas of …
Jul 2016
Warning Notice: East of England Ambulance Service NHS Trust
Section 29A warning notice concerning the trust's Emergency Operations Centres: mandatory training not kept up to date, call waiting times below national standards, insufficient staffing and cultural concerns across the three sites.
Jan 2025