Ambulance Handover Delays
290 items
2 sources
Significant delays in ambulance response times caused by prolonged patient offloading at hospitals, tying up critical resources.
Cross-Source Insight
Ambulance Handover Delays has been flagged across 2 independent accountability sources:
2 inquiry recs
288 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
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 with the first routine collection expected to be rolled out in 2026/27.
Accepted
In progress
PFD Reports (288) — showing 100 most recent
Yunus Hoque
Concerns: NWAS failed to communicate significant ambulance delays to callers, even when a patient's condition deteriorated from Category 2 to 1. This lack of follow-up risks further deaths.
Pending
Barbara Wingate
Concerns: Persistent issues with patient discharge delays due to inadequate community care provisions cause emergency department overcrowding and restrict timely access to acute care.
Pending
Liam Sutton
Concerns: Persistent delays in discharging medically fit patients due to inadequate community care provision block acute beds, leading to dangerous overcrowding in emergency departments and delayed critical care.
Pending
Janet Springall
Concerns: Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Pending
Heather Parkhill
Concerns: Persistent ambulance delays and resource unavailability continue to put lives at risk, despite ongoing multi-agency efforts to address these long-standing issues.
Pending
Dorothy Hoyberg
Concerns: Extreme pressure on ambulance services, operating at REAP Level 4, resulted in severe delays, unmet targets, and inability to make welfare calls, demonstrating that demand consistently outstrips capacity.
Response: The Department of Health and Social Care acknowledges ambulance service pressures and refers to the 2025/26 Urgent and Emergency Care Plan and the 10-Year Health Plan, which commit to reducing …
Responded
Suzanne Pemberton
Concerns: The hospital lacks any specialist dietetic service outside weekday working hours, risking delays in crucial nutritional interventions like naso-gastric feeding and potential non-adherence to re-feeding guides.
Response: East Suffolk and North Essex NHS Foundation Trust has undertaken a project to ensure all relevant ward areas receive consistent training related to dietetic care planning. They are also carrying …
Responded
Adam Hussain
Concerns: The urgent care pathway poorly serves serious systemic illnesses like sepsis, with critical patient information not reliably used by ambulance staff, leading to unnotified ambulance cancellations and unsafe call transfers.
Response: NHS England acknowledges the concerns and notes that a system-wide After-Action Review has been facilitated by the Integrated Care Board, with outcomes to be monitored by various governance bodies. They …
Response: East Midlands Ambulance Service has implemented several changes, including deploying senior clinicians in their Clinical Hub, ensuring clinicians review all information before transferring calls, and ceasing manual ITK push transfers …
Response: NEMS has ceased manually pushed calls, updated its Clinical Triage Guideline, introduced daily reviews of Category 3 calls, and established a Clinical Triage working group. They are also developing a …
Response: The ICB facilitated a system-wide After-Action Review, ceased some automatic call transfers to NEMS, reviewed and redefined the Urgent Care Clinical Hub service specification, and developed new analytics capabilities for …
Responded
Colin Brown
Concerns: Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic record accessibility.
Response: Yorkshire Ambulance Service will strengthen escalation and notification routes for patient safety incidents and reinforce through targeted clinical alerts that known high-impact risks like swallowing or choking should be explicitly …
Response: The Trust immediately implemented a policy ensuring patients in the Emergency Department are not given food without registered nurse oversight. They are also considering additional food mitigations and are rolling …
Responded
Lina Piroli
Concerns: Elderly and complex patients, especially those with dementia, suffer detrimental delays in overcrowded A&E departments unequipped to provide specialist care, due to a lack of available ward beds.
Response: NHS England outlines its national Urgent & Emergency Care plans to improve patient flow and reduce ED waits. Locally, the Trust is developing its frailty team, creating a dedicated frailty …
Response: The Department for Health and Social Care outlines the Government's 10-Year Health Plan and the Urgent and Emergency Care Plan for 2025/26, committing to investments (e.g., £250m) and initiatives to …
Responded
Liliane Bowden
Concerns: Significant ambulance delays, caused by high demand and prolonged hospital handovers, led to extended waits for Category 3 calls. This poses a serious risk to elderly and vulnerable patients needing prompt attention.
Response: South Central Ambulance Service disputes the report being issued to them, stating the core issue of handover delays lies with hospital trusts. They acknowledge the problem is widespread and explain …
Responded
Kathleen Ward
Concerns: The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient bed capacity.
Response: Hull Royal Infirmary is strengthening escalation processes for end-of-life patients and reinforcing compassionate communication. They plan a further rollout of Comfort Observations across the organisation, including the Emergency Department, and …
Responded
Gunaratnam Kannan
Concerns: There is a critical lack of joint policy and training among emergency and mental health services regarding Mental Capacity Act and Mental Health Act assessments, causing confusion over referral responsibilities.
Response: EMAS has embedded supporting tools like non-conveyance checklists and MCA prompts into their patient record system. They are actively working with system partners to establish robust referral pathways with local …
Response: Nottinghamshire Healthcare has delivered bespoke training and developed/shared two flow charts for staff on Mental Capacity Act assessments. They have also established a multi-agency group to improve joint working on …
Response: The RCGP states its curriculum already requires GPs to understand mental health legislation, including the Mental Capacity and Mental Health Acts, and that the curriculum was recently reviewed. They express …
Responded
Lewis Garfield
Concerns: Ambulance service communications were inadequate, leading to delayed clinician review and escalation. Lengthy hospital handover delays severely impact ambulance availability and emergency department flow.
Response: EMAS's Incident Review Group has discussed the concerns, and they are now implementing dynamic strategic conveyance daily and proactively initiating rapid handover requests during high demand. They are also actively …
Response: SCAS conducted an audit of the 999 calls, identifying one non-compliant call with documentation errors for which corrective action has been taken and learning shared directly with the call handler. …
Response: The Department for Health and Social Care has published an Urgent and Emergency Care Plan for 2025/26, committing nearly £450 million of capital investment and implementing additional surge capacity and …
Response: University Hospitals of Northamptonshire has implemented numerous initiatives since January 2025, including front door streaming, SDEC, Frailty services, discharge lounges, and Rapid/Acute Assessment Units. They have also introduced a NerveCentre …
Responded
Brian Ingram
Concerns: Inadequate staff introductions, family exclusion leading to incomplete patient history, poor inter-organisational information sharing, and incomplete patient assessments by triage staff resulted in missed symptoms.
Overdue
Zara Cheesman
Concerns: Emergency medical services lacked detailed understanding of child assessment issues, relied on incorrect physiological scoring, and had insufficient audit, monitoring, and professional development for staff on paediatric guidelines.
Overdue
Ricky O’Connell
Concerns: Ambulance response times are severely impacted by significant delays in clearing emergency departments and high demand for services, exacerbated by challenges in primary care access and regional turnaround issues.
Responded
Maureen Batchelor
Concerns: The Emergency Department consistently treats patients in corridors due to severe overcrowding and insufficient clinical space, despite ongoing efforts, posing an unacceptable risk to patient safety.
Overdue
Robyn Chambers
Concerns: Significant delays in ambulance dispatch were caused by prolonged handover times at emergency departments, potentially impacting patient care despite not affecting the specific outcome in this case.
Responded
Doreen Swann
Concerns: Persistent delayed hospital discharges due to social care bed shortages force high-falls-risk patients to remain in acute settings, straining resources and potentially compromising patient safety and bed availability.
Responded
David Gifford
Concerns: Paramedic training insufficiently addresses subtle presentations of vascular emergencies, like abdominal aortic aneurysms, increasing the risk of missed diagnoses when classic symptoms are absent.
Responded
Brenda Fisher
Concerns: Keeping patients for prolonged periods in unsuitable Emergency Department corridors, not designed for continuous care and observations, presents an inherent and residual risk of death.
Responded
Valerie Hill
Concerns: Long-standing, systemic ambulance handover delays in Wales persist at intolerable levels, with risks remaining due to a disconnect between ambulance service rostering expectations and actual hospital capacity.
Responded
Brian Garrick
Concerns: Ambulance response times are severely delayed due to prolonged patient handovers at acute hospitals, preventing crews from returning to service.
Responded
Jeanette Sidlow Beech
Concerns: Critical ambulance delays, exacerbated by significant hospital handover issues and a lack of social care, lead to patients awaiting discharge, blocking emergency departments and severely jeopardizing lives.
Responded
James Smith
Concerns: Inadequate social care provision leads to hospital discharge backlogs, causing severe ambulance handover delays and ED crowding, significantly increasing mortality risks for patients needing emergency care.
Responded
Paul Burke
Concerns: Persistent, multi-factorial delays in ambulance response times, coupled with hospital handover issues and system pressures, are causing significant waits for urgent pre-hospital care and pose a risk of future deaths.
Responded
Bernard Lyon
Concerns: Systemic failures include an under-managed care home using agency staff with language barriers, poor inter-agency communication, and severe overcrowding in hospital emergency departments causing treatment delays.
Responded
Sandra Millard
Concerns: The NHS Pathways triage tool does not consistently prompt additional questions for patients unable to move from any position, potentially missing risks associated with prolonged immobility.
Responded
Andrew Waters
Concerns: Significant ambulance handover delays, emergency department crowding, and inadequate social care provision are leading to increased mortality risk for patients awaiting emergency treatment and discharge.
Responded
Jack Shields
Concerns: An ambulance crew failed to recognise a patient's critical deterioration into cardiogenic shock and incorrectly prioritised their backup request, resulting in a prolonged delay to definitive medical care.
Responded
Lachlan Campbell
Concerns: Critical ambulance response delays, caused by extensive hospital handover times, prevented timely conveyance of a patient to hospital, which an expert stated would have prevented their death.
Responded
Kenneth Clayton
Concerns: Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management protocols.
Responded
Jeffrey Tyler
Concerns: Ambulance call handlers failed to clinically override the dispatch system's categorization, maintaining a low priority despite clear evidence of the patient's severe, deteriorating, and unmonitored condition.
Responded
Diana Fairweather-Purkis
Concerns: Insufficient ambulance availability leads to delayed patient attendance, exacerbated by excessive handover delays at hospitals, hindering ambulance crew release and further impacting response times.
Responded
Dorothy Reid
Concerns: Persistent hospital bed blocking by discharged patients causes excessive A&E waiting times, deterring critically ill patients from seeking care and increasing the risk of death.
Responded
Wyllow-Raine Swinburn
Concerns: Significant delays in connecting 999 calls to Emergency Call Takers and subsequent ambulance response times pose a risk, indicating a need for systems improvement in call handling.
Responded
Nicola Owens
Concerns: Persistent ambulance delays are caused by hospital handover backlogs, which stem from a lack of social care packages for discharged patients, severely reducing emergency response capacity.
Responded
Graham Whiteley
Concerns: Prolonged ambulance response times are caused by severe hospital handover delays, resulting in significant lost ambulance capacity and ongoing risk to critically ill patients.
Responded
Jackson Yeow
Concerns: Routine corridor care in the emergency department impedes clinical assessment, delays ambulance handovers, and normalizes unsafe practices due to significant delays in discharging medically fit patients.
Responded
Andrew Lewis
Concerns: Systemic and prolonged ambulance service capacity issues, coupled with extensive hospital handover delays, led to extreme response times, with national concerns about oversight and unaddressed PFD reports.
Responded
Charles Devos
Concerns: Extreme operational pressure on ambulance services, exacerbated by inadequate social care, causes excessive 999 call delays and unallocated calls. This forces call handlers to resort to risky mitigating measures like recommending self-conveyance.
Responded
Junior Powell
Concerns: Significant hospital delays in patient review and admission, caused by staff shortages and social care discharge bottlenecks, led to a critical delay in definitive treatment for an aortic dissection, contributing to the patient's death.
Overdue
Colin Wiles
Concerns: A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.
Responded
Joel Colk
Concerns: NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.
Responded
Vera Spencer
Concerns: Low ambulance service categorisation of falls leads to dangerously long waits for elderly patients, increasing risks of serious complications like pneumonia and pressure damage, exacerbated by the absence of an out-of-hours falls service.
Responded
Simon Boyd
Concerns: Ambulance response times are failing national targets, and call handler scripts misleadingly imply dispatch. Additionally, ambulance responses can be cancelled without informing the caller.
Responded
Susan Shipley
Concerns: An amputee was incorrectly deemed 'fit to sit' for transfer without proper assessment or documentation, resulting in a fall and hip fracture. This indicates systemic failures in patient assessment and incident learning.
Responded
Shirley Hughes
Concerns: The Medical Priority Dispatch System (MPDS) for ambulance calls, designed years ago, is failing to meet current response targets due to resource issues, raising concerns that lives are being put at risk by outdated prioritization.
Responded
Alice Clark
Concerns: Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
Responded
Peter Parker
Concerns: Significant ambulance response delays, exceeding the expected survivability of severe injuries, were caused by ambulances being held up at Emergency Departments, preventing them from attending new calls.
Responded
Henry Willems
Concerns: Ambulance service failed to meet Category 2 response times by over two hours due to extreme surge levels and significant vehicle delays at hospitals, likely leading to the deceased's preventable death.
Responded
Kevin Woods
Concerns: Persistent ambulance handover delays are linked to inadequate social and community care, with no single organisation responsible for ensuring sufficient provision or overall patient safety from these systemic failures.
Responded
Dennis Harry
Concerns: Inadequate social care and community health provision lead to delayed hospital discharges, causing ED crowding and systemic ambulance delays. There is no single organization responsible for ensuring sufficient social care or overseeing patient safety risks from these delays.
Responded
Susan Dear
Concerns: Chronic ambulance shortages, severe response delays, and hospital handover issues put patient lives at risk. This systemic problem is exacerbated by understaffing and delays in patient discharge from hospitals.
Responded
Philip Ross
Concerns: The ambulance service's failure to timely clinically validate Category 3 and 4 calls, coupled with extended response times, places deteriorating patients at risk of early death.
Responded
John Howlett
Concerns: Systemic hospital capacity issues led to a patient waiting 22 hours in a corridor. Separately, a care home with existing safeguarding concerns failed to adequately monitor a resident's nutritional status and fluid intake.
Responded
Daniel Klosi
Concerns: A distressed neurodiverse child did not receive full observations for over four hours in a busy emergency department, leading to a catastrophic cardiovascular compromise and highlighting challenges in assessing such patients.
Responded
John Codd
Concerns: Persistent and severe crowding in the Emergency Department, caused by lengthy delays in discharging patients, significantly impacts cubicle availability and jeopardizes future patient care.
Responded
Marjorie Michael
Concerns: Persistent lengthy ambulance response delays for critical emergencies are caused by acute hospitals failing to promptly release ambulances, despite ongoing efforts, directly contributing to patient deaths.
Responded
Regan Smith
Concerns: An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.
Responded
Josh Smith
Concerns: Persistent ambulance response delays, both for emergency calls and hospital handovers, continue to fall short of national targets, impacting timely patient care in the community.
Responded
Harry Dunn
Concerns: Severe ambulance resource shortages and lengthy hospital handover delays prevented timely emergency response, failing to meet target standards and posing a continuing risk of future deaths.
Responded
John Howe
Concerns: Late patient discharges persisted at Manchester Royal Infirmary, with ambulance services unaware of updated timings. Additionally, a Serious Incident Review was delayed and contained factual inaccuracies.
Responded
Bernard Compton
Concerns: The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely response for a critical cardiac condition.
Responded
Sylvia Evans
Concerns: An extreme 9-hour ambulance delay for a patient with a life-threatening emergency, partly caused by hospital handover issues, resulted in her death before paramedics arrived.
Responded
Bobilya Mulonge
Concerns: Persistent delays in paramedics attending Category 2 calls are caused by ambulances being unable to clear Accident and Emergency departments promptly.
Responded
Michael Clarke
Concerns: Persistent significant delays for Category 3 ambulance calls and a lack of specific sepsis trigger questions on the ambulance pathway compromised timely emergency response, particularly for suspected sepsis.
Overdue
Sophie Hindmarsh
Concerns: A significant ambulance response delay was caused by severe hospital offloading delays, tying up vital resources and preventing timely emergency care.
Responded
Richard Carpenter
Concerns: Ambulance response targets are consistently missed due to chronic hospital handover delays and bed blocking caused by insufficient community care packages, increasing the risk of preventable deaths for patients requiring timely hospital transfer.
Responded
Jade Griffiths-Jones
Concerns: West Midlands Ambulance Service consistently misses response targets due to chronic hospital handover delays, significantly compromising ambulance availability and posing a risk to patient lives.
Responded
Paul Dow
Concerns: Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Responded
Robert Prowse
Concerns: Systemic ambulance delays, directly linked to a lack of social care provision causing delayed hospital discharges, contributed to the death by preventing timely treatment and exacerbating emergency department overcrowding.
Responded
Patricia Eyken
Concerns: Systemic ambulance delays, caused by insufficient social care provision leading to delayed hospital discharges and subsequent emergency department overcrowding, critically impacted timely access to life-saving treatment.
Responded
Jean Walker
Concerns: An ambulance service failed to meet response targets for a Category 2 call, exacerbated by significant hospital offloading delays that tied up vital resources.
Responded
Joseph Miller
Concerns: Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Responded
Peter Beresford
Concerns: Paramedic response delays for Category 2 calls are unresolved due to staff/vehicle shortages and exacerbated by ambulance handover delays at overcrowded A&E departments.
Responded
Jean Thomas
Concerns: Significant ambulance and hospital offload delays, far exceeding targets, led to the formation and exacerbation of a pressure sore due to prolonged patient immobility.
Responded
Joseph Cattle
Concerns: The Welsh Ambulance Service experienced significant delays in allocating an ambulance for an urgent call, partly due to hospital handover delays. The number of funded ambulances appeared insufficient.
Overdue
Severine Kelly
Concerns: Outdated medical training for bank staff, inadequate risk assessment updates, and poor emergency communication facilities contributed to delays in emergency response and patient care.
Responded
Rosie Young
Concerns: Trust employees lacked familiarity and specific training on the Mental Health Act Transportation Policy, leading to inadequate risk assessment and delegation during patient transfers.
Responded
Brian James
Concerns: Ambulance service instructions not to call back and inadequate welfare checks during delayed responses risk callers failing to recognize deterioration or feeling unable to re-contact emergency services, missing critical reassessment opportunities.
Responded
O’Shea Dover
Concerns: National ambulance guidance (JRCALC) should incorporate the recommendation to convey patients with unprogressing labour directly to an obstetrics unit, as per London Ambulance Service practice.
Responded
Lucas Pollard
Concerns: A Critical Care Team was not immediately dispatched, and an End Of Shift Policy was inappropriately applied, preventing a rapid response vehicle deployment, despite clear evidence of patient deterioration.
Responded
Donna Smith
Concerns: The ambulance service's call handling system failed to detect deteriorating patient condition and escalate the emergency, resulting in a significant delay in response time.
Responded
Dennis King
Concerns: Significant ambulance delays and confusion in transfer categorisation between hospitals, alongside an inadequate action plan, undermined the timely delivery of urgent, centralised cardiac care.
Responded
Sarah Mitchell
Concerns: Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access to her medical records detailing a controlled dispensing regime.
Responded
James Campion
Concerns: Significant delays in 999 call triage and ambulance dispatch, stemming from high demand, critically impacted the timely provision of medical and psychiatric assistance for an overdose.
Overdue
Shaun Parks
Concerns: An excessive ambulance response time was caused by insufficient emergency medical dispatchers and significant hospital patient offloading delays, tying up resources and impacting emergency call response.
Overdue
Vivienne Greener
Concerns: A lack of out-of-hours emergency endoscopy and insufficient Emergency Department staff contribute to ineffective triage and ambulance offloading delays. Unclear clinical protocols and inadequate sharing of investigation learning also pose risks.
Responded
John Taylor
Concerns: Paramedics failed to adequately check an unlocked door, leading to a 30-minute delay awaiting police entry, an issue not addressed in the internal investigation. Alternative transport options were also not considered.
Responded
William Gray
Concerns: Hospital doctors were unaware of JRCALC guidelines for adrenaline in life-threatening asthma. Ambulance guidelines lacked clarity on managing severe asthma attacks, and the trust's investigation failed to learn from repeat incidents.
Responded
David Briggs
Concerns: Significant ambulance response delays resulted from insufficient resourcing and extended patient offloading times at hospitals, preventing timely emergency call responses.
Overdue
Gerald Cruse
Concerns: Elderly patients with complex needs on surgical wards receive inadequate holistic care due to a national shortage of geriatric specialists. Ambulance staff demonstrated inconsistent fall risk assessment and insufficient training.
Overdue
John Seagrove, Pauline Humphris and Patricia Steggles
Concerns: Chronic and worsening ambulance handover delays at emergency departments are severely impacting response times and leading to staff burnout and recruitment difficulties.
Responded
Kenneth Heard
Concerns: Ambulance response times are severely impacted by extensive and persistent handover delays at Treliske and Derriford hospitals, with patients still waiting over 12 hours in ambulances despite mitigating measures.
Responded
Lynda Blackmore
Concerns: Significant ambulance handover delays at hospitals are severely impacting emergency response times, causing patients to wait many hours for treatment or conveyance. These delays pose a critical risk to patient safety.
Responded
Christopher Hart
Concerns: Persistent and significant ambulance non-availability in the East of England region led to extreme delays, where prompt arrival and early treatment could have saved a patient's life.
Responded
Michael Vincent
Concerns: An elderly patient suffered a fatal cardiac arrest after a ten-hour ambulance delay following a fall. The severe missed response target highlights a risk of future deaths from prolonged lying and related injuries.
Overdue
Gina Bywater
Concerns: Persistent and severe ambulance non-availability in the East of England led to nearly 10-hour delays. Expert evidence indicates that prompt ambulance arrival and early treatment could have saved the patient's life.
Responded