Ambulance Handover Delays
Significant delays in ambulance response times caused by prolonged patient offloading at hospitals, tying up critical resources.
591 items
10 sources
2 inquiries
Source spread
Where this theme appears
Ambulance Handover Delays has been flagged across 10 independent accountability sources:
2 inquiry recs
296 PFD reports
11 committee recs
6 PPO recs
4 IOPC recs
2 IMB reports
2 IMB recs
1 Article 2 learning point
67 PHSO decisions
200 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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 with the first routine collection expected to be rolled out in 2026/27.
Accepted
In progress
PFD Reports (296) — showing 50 strongest matches
Lucy Hannah Rose Bailey
Concerns: Concerns were raised regarding the adherence to or adequacy of guidelines for managing dystocia, which was identified as a known hazard.
Response (South Central Ambulance Service): The South Central Ambulance Service has updated its clinical practice guidance on the management of shoulder dystocia, incorporating advice from specialists in obstetrics and midwifery, and issued it to Medical …
Responded
Michael Sweeney
Concerns: Police training on 'excited delirium' is not widely understood by other health professionals, risking miscommunication and missed diagnoses of underlying medical conditions. Standardising the term to 'extreme agitation' is needed.
Response (Metropolitan Police Service): The Metropolitan Police Service has addressed potential information gaps for civil staff with practice notes and in-house training, and developed a detailed joint agency call-handling protocol with the London Ambulance …
Response (London Ambulance Service): The London Ambulance Service does not agree with the recommendation to use the term 'extreme agitation', preferring 'acute behavioural disturbance' (ABD). They have engaged with police and reviewed guidance, and …
Responded
David Selman
Concerns: An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.
Overdue
Barnabas Newlyn
Concerns: Road transfer times for time-sensitive critical care, particularly neurosurgical emergencies, are too long, necessitating earlier consideration and use of air transfer services.
Response (NHS England): NHS England will issue interim guidance on protocols for time-sensitive critical care transfers, offer training to critical care staff in retrieval, mobilise commissioning arrangements for standardising protocols, and commission a …
Responded
Chloe Grace Flavell
Concerns: The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Overdue
Albert James Hand
Concerns: The coroner reported concerns about a patient with a head injury waiting over an hour and a half for transport to hospital, insufficient ambulance crews in the Luton and Bedfordshire area, and protocols for dealing with emergency calls potentially putting patients at risk.
Response (East of England Ambulance Service NHS Trust): The East of England Ambulance Service NHS Trust has reviewed its Demand Management Plan, commenced issuing a clinical manual to staff, and is commissioning an upgrade to the Computer Aided …
Responded
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Frederick Pring
Concerns: Current practices for patient handover at Emergency Departments lead to unacceptable delays, keeping ambulances occupied and unavailable for other critical calls.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service NHS Trust and Betsi Cadwaladr University Health Board are working towards completing an All Wales Handover Policy for patient handover between clinical teams. The Health Board …
Responded
Keith Thomas Graham
Concerns: The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including summoning clinicians, CT scanning contraindications, and minimising time to surgery when indicated.
Overdue
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Response (Greater Manchester Police): Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different …
Response (North West Ambulance Service NHS Trust): NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint.
Response (Department of Health2): The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not …
Responded
Sally Perrons
Concerns: No specific concerns were detailed in the provided text for summarization.
Response (Association Ambulance Chief Executives): The National Ambulance Sector will require the use of either a digital ETC02 monitoring device or full waveform capnography for every intubation with immediate effect. Waveform capnography will be considered …
Responded
Liam Coleman
Concerns: There was an insufficient number of ambulances available to adequately cover urgent Red 1 and Red 2 calls, indicating a critical resource shortage.
Overdue
Thomas Maher
Concerns: Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Response (Central Manchester University Hospital NHS Trust): The hospital has implemented a new process to scan all records for deceased patients and those involved in high-level incidents into the electronic patient records system as a priority. Ward …
Responded
Anthony Offord
Concerns: Emergency medical dispatch staff lacked training on respiratory distress signs. Protocols were absent for ambulance crew "stand-offs," considering alternative support, or managing ambulance availability during meal breaks.
Response (Yorkshire Ambulance Service NHs Trust): Yorkshire Ambulance Service reviewed training for EMD staff, clarified management involvement in 'stand off' decisions, and reinforced consideration of alternative support methods. They are also reviewing the meal break policy …
Overdue
Rosalind Adshead
Concerns: A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
Overdue
William Davies
Concerns: Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.
Response (Care UK): Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National …
Responded
David Ince
Concerns: Emergency ambulance staff frequently fail to routinely hand over patient ECG traces to A&E personnel, leading to critical information being missed during admission.
Overdue
Elizabeth Leah
Concerns: Severe ambulance service understaffing and resource shortages led to dangerous delays, resulting in an elderly patient with a broken leg being advised to take a taxi to the hospital. Systemic issues were exacerbated by A&E delays and bed blocking.
Response (Department of Health): NWAS has increased staffing levels in control rooms and on the road, and is developing Advanced Community Paramedic roles. They are also increasing the use of volunteer services and have …
Responded
Sabrina Stevenson
Concerns: Worsening ambulance response times, staffing shortages, unaddressed training issues (e.g., pregnancy testing, extraction), and a lack of system improvements like automated re-categorisation pose ongoing risks.
Response (College of Paramedics): The College of Paramedics commits to writing to NHS ambulance services and HEIs to offer assistance in recruiting paramedics, advising them of revised Paramedic Curriculum Guidance. It will also advise …
Response (London Ambulance Service): London Ambulance Service secured additional investment of £27.2m to improve response times, increase staffing, and improve productivity and are on track to recruit 850 staff in 2015/16. The LAS has …
Response (NHS England1): NHS England details actions taken with the LAS, including weekly performance reviews, additional funding of £27.2m for 2015/16 to increase staffing and capacity, and improve ambulance response times, with a …
Responded
Noel Jones
Concerns: Delays in patient acceptance by the hospital and the absence of out-of-hours vascular surgery or interventional radiology services likely contributed to the deceased's death.
Response (Worcestershire NHS Trust): The Trust has reviewed its out-of-hours arrangements for vascular surgery/interventional radiology for critically ill patients needing transfer.
Responded
Diana Hughes
Response (Gloucestershire Hospitals NHS Trust): The Trust is considering amending the WHO surgical checklist and reviewing its documentation policy to improve recording of special instructions for post-operative care. Progress will be monitored through the Safety …
Responded
Barbara Patterson
Concerns: The Pathways system has a fault preventing timely CPR advice for agonal breathing, and ambulance dispatch was delayed due to paramedic shortages and handover issues at hospitals.
Response (Department of Health): NHS Pathways has provided a response to concerns and will be meeting to discuss these issues. NHS England plans to publish guidance to help ambulance services develop new ways of …
Response (CQC): The CQC will include concerns about ambulance dispatch procedures as part of their planned comprehensive inspection, and will discuss ambulance dispatch management and handover processes with the North East Ambulance …
Response (North East Ambulance Service NHS Trust): The North East Ambulance Service refers to their attached response which repeats the evidence given at the inquest and highlights the national operational standard for ambulance trusts.
Responded
George Boulton
Concerns: Delays in emergency stroke care arose from the GP failing to escalate, a bed bureau lacking emergency re-routing, and ambulance services not classifying a stroke as an immediate emergency, risking critical treatment windows.
Response: East Midlands Ambulance Service acknowledges the coroner's concerns and explains their current processes for urgent patient transfers. NHS England describes a broader review of urgent and emergency care and the …
Overdue
Colin Moulton
Concerns: Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.
Response (Department of Health): The Department of Health acknowledges the concerns, noting local resolution and NWAS response. They provide national context including handover procedures, NHS England review of urgent and emergency care, enhanced summary …
Overdue
David Sweeney
Concerns: A call to the London Ambulance Service regarding an unconscious man did not prompt a red prioritisation, raising concerns about the handling of calls regarding unconscious patients.
Overdue
John Robinson
Concerns: The unavailability of a psychiatric bed for Mr Robinson led to his deteriorating condition and death, raising concerns about insufficient mental health resources in the area.
Overdue
Kala Skinner
Concerns: Clinical advisors missed critical 'red flags' and gave inappropriate advice due to inadequate training, mentoring, and auditing, leading to failures in recognising serious conditions and safeguarding patients.
Overdue
Ronald Bonfield
Concerns: Inconsistent practices for monitoring district nurse compliance with delegated INR testing across GP surgeries create a risk of unmonitored over-anticoagulation.
Overdue
Adil Habib
Concerns: Lack of specific gate location information for prisons during 999 calls, compounded by London Ambulance Service's system not uniformly supporting alternative gate selection across all London prisons.
Response (HM Prison and Probation Service): HM Prison and Probation Service has completed a DVD covering principles of safe restraint, medical complications, and actions to take when prisoners conceal items in their mouths, which will be …
Response (London Ambulance Service NHS Trust): The London Ambulance Service has augmented its computer system with additional gate information for HMP Pentonville and shared learning about confirming addresses when taking calls from prisons in a team …
Overdue
Stuart Knight
Concerns: Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.
Response (East Midlands Ambulance Service): EMAS has increased its frontline resources, implemented a 'hear and treat' system, and introduced a single Ambulance Technician vehicle in East Lincolnshire. These initiatives aim to increase ambulance availability for …
Responded
Mrs Withers
Concerns: Systemic policy deficiencies in emergency services included failing to obtain patient medical history during 999 calls, inadequate call-back procedures, poor data saving, and inefficient handover to A&E.
Overdue
Christopher Connor
Concerns: Ambulance response was delayed, only arriving after police expedited the call, indicating potential issues with emergency service dispatch or prioritization.
Response (Welsh Ambulance Service NHS Trust): Following an investigation, the Welsh Ambulance Services NHS Trust addressed failings by an individual staff member and provided additional education and support to call takers involved in the incident; the …
Responded
Madhumita Mandal
Concerns: An emergency department streaming model that relied on untrained receptionists without medical observations led to critical delays in patient assessment by qualified healthcare professionals.
Overdue
Matthew Crowley
Concerns: A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Overdue
Mandeep Singh
Concerns: Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Response (North East Ambulance Service): NEAS has improved its paramedic resource base, with improved attrition rates, and is working to educate the public about appropriate use of services. They work with other agencies for road …
Responded
Monica Lewis-Hinds
Concerns: The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.
Overdue
Luke Ayres
Concerns: Delays in emergency response were caused by a cut-off 999 call, a staff member providing ambulance information from a distance without current patient status, and paramedics not being immediately escorted to the ward.
Response (Birmingham and Solihull NHS Trust): The trust has improvement measures in place including implementation of a single anti barricade system, replacement of 70 observation panels and piloting of a new clinical handover tool. The trust …
Responded
Carl Thompson
Concerns: Life-saving equipment used by lifeguards was defective or missing, including a defibrillator without batteries, causing significant resuscitation delays. There were also concerns about lifeguard training and information provided to holidaymakers.
Overdue
Ronald Hamer
Concerns: An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Services NHS Trust has developed an action plan and is monitoring progress through a Task and Finish Group of senior staff, led by the Director of Quality, …
Overdue
Mia Gibson
Concerns: Over-reliance on maternal observations in obstetric emergencies overlooked fetal risk, and ambulance dispatch suffered from poor meal break management and resource shortages. This led to critical delays in emergency response and hospital transfer.
Overdue
Peter Scott
Concerns: The ambulance service is critically under-resourced, operating frequently under severe capacity constraints due to high demand and recruitment issues, exacerbated by hospital handover delays.
Response (East Midlands Ambulance Service): East Midlands Ambulance Service (EMAS) has discussed the concerns within the Coroners Working Group and developed an action plan, reintroduced monthly meetings with hospitals and commissioners to improve ambulance turnaround, …
Response (Hardwick CCG): Hardwick CCG, on behalf of 22 CCGs across the East Midlands region, will undertake a jointly commissioned external strategic review focussing on capacity and demand with EMAS, with implementation over …
Response (NHS England): NHS England notes that an external strategic review of capacity and demand will be undertaken and that the 2016/17 contract settlement also provided additional funding to EMAS in order to …
Response (NHS Improvment): NHS Improvement is working with the East Midlands Ambulance Service NHS Trust to address resourcing issues and improve response times and highlights that in 2015/16, the trust carried out a …
Overdue
Valerie Ellis
Concerns: Inadequate discharge counselling for a vulnerable patient on medication, coupled with concerns about 111 health advisor training and imprecise algorithms. A call-back was prematurely closed and a joint investigation has not occurred.
Response (South East Coast Ambulance Service NHS Trust): The Ambulance Service states it has met NHS Pathways training requirements and believes further algorithm concerns should be directed to the Department of Health. They are open to sharing their …
Response (Western Sussex Hospital NHS Trust): The Trust launched a NOAC alert card in October 2015 and introduced a Standard Operating Procedure for pharmacy staff. They will also place a NOAC card in the medication bag …
Response (Integrated Care 24 Limited): IC24 has implemented new Failed Contact Guidance and software to prevent premature call closure. They have reviewed their induction training program and specifically included information on accessing NHS 111 reports …
Responded
Joyce Ravenhill
Concerns: A lack of operational policy prevented effective communication of an urgent doctor's appointment need between triage nurses, relying instead on automated electronic information.
Responded
Pamela Conway
Concerns: Persistent and unacceptable delays in patient offloading from ambulances at hospitals continue to render ambulance resources unavailable for other calls, creating ongoing risks to public safety.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service NHS Trust has made progress against key actions identified in an attached action plan, with the most significant impact from the Welsh Health Circular regarding hospital …
Response: The University Health Board is scrutinizing two working action plans relating to the case, which will be monitored by the Quality and Safety Group.
Responded
Kyles Lowes
Concerns: Long emergency care journey times and a single paramedic crew after 10 pm in a busy area create significant risk of delayed responses. The proposed solution relies on staff goodwill and doesn't fully mitigate risks.
Response (Northumberland Clinical Commissioning Group): The CCG is working with various organisations to review services in Alnwick and Berwick, to share staff and skills, and NEAS will deploy an additional Rapid Response Paramedic in the …
Overdue
Joshua Smith
Concerns: Emergency services exhibited delayed and uncoordinated response, difficulty in pinpointing location, and failed to follow joint command protocols (JESIP), contributing to critical delays.
Response (Maritime Coastguard Agency): The Maritime Coastguard Agency has updated guidance and modified training packages. All Coastguard tactical commanders attend JESIP courses and strategic commanders attend MAGIC courses; every officer completes online JESIP training. …
Response (Northumberland Fire and Rescue Service): Northumberland Fire and Rescue Service reaffirmed procedures for 999 calls, implemented joint working principles with blue light partners, and trained staff in JESIP. Future plans involve including HM Coastguard and …
Response (Northumbria Police): Northumbria Police and the North East Ambulance Service are considering expert advice from Mountain Rescue regarding phone tracking software. HM Coastguard is considering improving their Airwave capability to facilitate communication. …
Overdue
Brian Mills
Concerns: Consistently high levels of outstanding emergency calls and excessively long waiting times, far exceeding target response times, pose a significant risk.
Response (East of England Ambulance Service NHS Trust): The trust is delivering training to Coroner's Officers around the country in relation to the coding and resourcing of 999 calls. It has also increased clinicians in the Emergency Operations …
Responded
Mary Muldowney
Concerns: Critical delays occurred in transferring a patient for essential neurosurgery due to a lack of intensive care beds, despite the time-sensitive nature of the condition, likely contributing to death.
Overdue
Dipa Lad
Concerns: The ambulance service deviated from national resuscitation guidance without providing clear staff guidance or training, leading to poor staff awareness of critical policy changes and inadequate resuscitation techniques.
Response (East Midlands Ambulance Service NHS Trust): EMAS reviewed its procedures and provided guidance for clinicians dealing with cardiac arrest patients, including additional guidance around futility aligned with BMA, RCUK, and RCN guidance. All clinical staff receive …
Responded
Christopher MacMorland
Concerns: Despite being under the care of gastroenterologists, the patient was not treated in a specialist gastroenterology ward despite multiple requests, and consultant requests for patient transfer to specialist wards are commonly not implemented.
Response (Portsmouth Hospitals NHS Trust): The Trust implemented a 'buddy' ward system where patients of certain specialties are cohorted only into the appropriate specialist ward or specific buddy ward.
Responded
Committee Recommendations (11)
#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, …
Gov response: Accept in principle. The Government recognises the importance of ensuring that the NHS has the capacity it needs to provide safe and effective everyday care for patients, whilst also responding to need directly created by …
Under Consideration
#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 …
Gov response: Accept in principle. The Government recognises that 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 …
Under Consideration
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: February 2024 3.2 NHS England is working to tackle unwarranted variation in performance. Making improvements to Emergency Departments and ambulance performance requires working between …
Accepted
#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. …
Gov response: The government agrees with the Committee’s recommendation. improvements to Emergency Departments and ambulance performance requires working between secondary, primary, community and social care so the Urgent and Emergency Care (UEC) tiering support offer is taking …
Accepted
#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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#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 …
Gov response: 5.1 The government disagrees with the Committee’s recommendation. 5.2 While the department approaches all its work in a spirit of continuous improvement, the government nonetheless disagrees with the Committee's recommendation. Parliament has itself articulated the …
Not Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million invested in …
Accepted
#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 …
Not Addressed
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: February 2024 3.2 NHS England is working to tackle unwarranted variation in performance. Making improvements to Emergency Departments and ambulance performance requires working between …
Accepted
#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
Gov response: The government agrees with the Committee’s recommendation. improving patient flow through hospitals, with plans to boost capacity with 5,000 extra core General and Acute beds. In addition to this, NHS England is working with systems …
Accepted
#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 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 Since Spending Review 2021, the government has made available up to £8.6 billion in additional funding over 2023-24 and 2024-25 for adult social care …
Accepted
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. Do you accept the …
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 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
PHSO Casework Decisions (67)
P-002850 — East Midlands Ambulance Service NHS Trust
Mrs P complains of a six-hour delay between the ambulance arriving at hospital and her father being handed over to emergency department staff.
NHS in England
Upheld
Aug 2024
P-003279 — Torbay and South Devon NHS Foundation Trust
Mrs L complains about the treatment given to her mother in November 2022. She says there was a delay in admission to the emergency department and her mother waited outside in an ambulance for 13 hours. She also complains about delays and treatment once admitted.
NHS in England
Partly Upheld
Jan 2025
P-002890 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mr A complained about his care for a urinary tract infection and sepsis after his admission by ambulance to A&E.
NHS in England
Aug 2024
P-003534 — North West Ambulance Service NHS Trust
Mrs J complains about long waiting times for an ambulance to be sent to her husband.
NHS in England
May 2025
P-003752 — A practice in the East Riding of Yorkshire …
Mr A raised concerns about the Ambulance Trust and Practice. Specifically that his wife waited seven hours for an ambulance following a stroke and the Practice failed to complete a medication review and continued to prescribe medication despite his wife suffering side effects.
NHS in England
Jul 2025
P-004024 — South Western Ambulance Service NHS Foundation Trust
Mrs L complains on 1 March 2024, the Trust failed to provide appropriate care to her husband Mr L. She complains several telephone calls to the Trust for an ambulance were categorised incorrectly and the Trust took nearly three hours to send an ambulance for her husband.
NHS in England
Sep 2025
P-004654 — South Western Ambulance Service NHS Foundation Trust
Mrs A complains that the Trust delayed sending an ambulance, did not understand the seriousness of the incident and prevented a rapid response vehicle from attending to her son on 19 December 2022. She also raises concerns about the Trust’s complaint handling.
NHS in England
Partly Upheld
Jan 2026
P-001544 — University Hospitals Of Leicester NHS Trust
Mrs R complains about delays in care and treatment by the Ambulance Service and the Trust when she fractured her neck.
NHS in England
Sep 2022
P-002374 — London Ambulance Service NHS Trust
Mrs I complains about how long it took for the ambulance to arrive and how this affected her father's treatment.
NHS in England
Dec 2023
P-002603 — East of England Ambulance Service NHS Trust
Mrs L complains the Ambulance Trust should have taken her husband to hospital due to his symptoms. Mrs L also complains about the care and treatment the East Suffolk and North Essex NHS Foundation Trust gave to her husband when he went to A&E with chest and back pain.
NHS in England
May 2024
P-003125 — Wirral University Teaching Hospital NHS Foundation Trust
Mr Q complains the hospital said the delayed ambulance made no difference to the treatment it could offer or how soon it could start this.
NHS in England
Nov 2024
P-003241 — University Hospitals of Leicester NHS Trust
Mr E complains that on 14 October 2022 the University Hospitals of Leicester NHS Trust delayed admitting his wife to the emergency department because ambulances were backed up and this delayed his wife being diagnosed with sepsis. He also complains about the treatment once she was admitted.
NHS in England
Dec 2024
P-003239 — North West Ambulance Service NHS Trust
Mrs L complains the ambulance Trust left her mother without the appropriate treatment for 30 hours.
NHS in England
Dec 2024
P-003275 — North East Ambulance Service NHS Foundation Trust
Mrs G complains about the care and treatment North East Ambulance Service NHS Foundation Trust provided to her husband, Mr G, when he fell ill on 20 December 2023. She complains it took staff too long to get him into the ambulance. She also complains the staff involved have given …
NHS in England
Jan 2025
P-003319 — North West Ambulance Service NHS Trust
Mr O complains that in October 2023 the Trust failed to recognise his father needed urgent treatment, meaning he waited 14 hours for an ambulance.
NHS in England
Feb 2025
P-003504 — Yorkshire Ambulance Service NHS Trust
Mr S complains the ambulance took too long to arrive when he called 999 for his partner in September 2022.
NHS in England
Apr 2025
P-003657 — East Kent Hospitals University NHS Foundation Trust
Mr P complains about the ambulance and hospital Trust’s management of his father, Mr B, when he collapsed due to an abdominal aortic aneurysm.
NHS in England
Partly Upheld
Jul 2025
P-004019 — Yorkshire Ambulance Service NHS Trust
Miss A complains about the care provided to her father, Mr B, by Yorkshire Ambulance Service NHS Trust (the Trust) when he was suffering a heart attack on 3 April 2023. Miss A also complains about the way in which the Trust handled her complaint.
NHS in England
Not Upheld
Sep 2025
P-003944 — Bradford Teaching Hospitals NHS Foundation Trust
Mrs P says both the Trust and the Ambulance Trust delayed diagnosing, treating, and transferring her son, Mr P, due to miscommunication and misdiagnosis.
NHS in England
Sep 2025
P-004036 — West Midlands Ambulance Service University NHS Foundation Trust
Miss N complains it took over five hours for an ambulance to arrive for her brother after he called 999 reporting breathing problems. She also complains the Ambulance Service failed to call back to check on him during that time.
NHS in England
Sep 2025
P-004246 — South East Coast Ambulance Service NHS Foundation Trust
Ms E complains about the service her aunt, Mrs F, received from the Trust following her calls to 999 about having symptoms of a stroke.
NHS in England
Oct 2025
P-004441 — West Midlands Ambulance Service University NHS Foundation Trust
Mr Y complains on behalf of his late mother, Mrs Y, about the delay with an ambulance arriving and lack of appropriate treatment for her low oxygen levels.
NHS in England
Partly Upheld
Dec 2025
P-004542 — South East Coast Ambulance Service NHS Foundation Trust
Mrs F complains paramedics from South East Coast Ambulance Service NHS Foundation Trust failed to take her to hospital for further investigations and communicated poorly towards her on 13 July 2024.
NHS in England
Dec 2025
P-004709 — Manchester University NHS Foundation Trust
Miss X complains about the service provided to her father by an ambulance and two acute trusts prior to his death.
NHS in England
Partly Upheld
Jan 2026
P-004687 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust did not have a doctor on site who could perform an endoscopy to treat her son's upper gastrointestinal bleed. She adds it delayed in transferring him to a different hospital that could perform this intervention.
NHS in England
Not Upheld
Jan 2026
P-001581 — North East Ambulance Service NHS Foundation Trust
Mr R complains about how the Trust categorised the 999 call he made for his son and how long it took for the ambulance to arrive
NHS in England
Oct 2022
P-001937 — London Ambulance Service NHS Trust
Mr X complains the ambulance arrived eight and a half hours after he called for an ambulance and by this time his brother had sadly died.
NHS in England
Apr 2023
P-002281 — North West Ambulance Service NHS Trust
Mr U complains the Trust failed to transport his mother to hospital several times between August and October 2021. He says the failed transport attempts were because the Trust did not carry out a risk assessment on his mother.
NHS in England
Nov 2023
P-002601 — South Central Ambulance Service NHS Foundation Trust
Mrs T complains about the way the Trust handled the emergency call her father made in September 2022. She complains the call was not put through to the ambulance service immediately, about how the call was handled and that it took too long for the ambulance to arrive.
NHS in England
May 2024
P-002649 — Barts Health NHS Trust
Miss E complains the Trust failed to admit her son after waiting a long time in the emergency department. Miss E explains her son was admitted the next day but she complains about the care and treatment he was given.
NHS in England
May 2024
P-002805 — East of England Ambulance Service NHS Trust
Mr G complains that between October and December 2019 doctors at the Practice and the Trust failed to identify his worsening heart failure. He also complains the Ambulance Trust failed to send an ambulance despite a 999 call.
NHS in England
Jul 2024
P-002882 — West Midlands Ambulance Service University NHS Foundation Trust
Mrs M complains that her mother suffered a leg injury because of failings in her care while she was being transferred in an ambulance in June 2022.
NHS in England
Aug 2024
P-002889 — Yorkshire Ambulance Service NHS Trust
Mr G complains the Yorkshire Ambulance Service NHS Trust's ambulance crew did not take his uncle to hospital for blood tests following a fall at home.
NHS in England
Partly Upheld
Aug 2024
P-003283 — South East Coast Ambulance Service NHS Foundation Trust
Mr A complains about the care and service provided to his partner, Ms B, by the NHS Trust on 9 and 10 October 2023.
NHS in England
Jan 2025
P-003405 — Royal United Hospitals Bath NHS Foundation Trust
Miss A complains that in April 2023, South Western Ambulance NHS Foundation Trust failed to record her father was experiencing head pain following a fall. She also complains that on admission to the Emergency Department, Royal United Hospitals Bath NHS Foundation Trust failed to act upon her father’s head trauma …
NHS in England
Mar 2025
P-003560 — Northern Care Alliance NHS Foundation Trust
Mr W complains his father had to wait a considerable amount of time to be seen when he was transferred to the emergency department in November 2023.
NHS in England
May 2025
P-003668 — The Royal Wolverhampton NHS Trust
Mrs L complains the Trust failed to follow-up on her father’s cardiac care between September 2020 and May 2023. She says when her father fell severely ill on 20 May 2023, the Trust failed to act on an ambulance pre-alert and was not prepared for his imminent arrival and deteriorating …
NHS in England
Partly Upheld
Jul 2025
P-004135 — A practice in the Worthing area
Mrs U complained about the actions of three organisations involved in her father’s care. She was unhappy with the Practice’s management of his conditions, the treatment centre’s handling of a referral and how long the Trust took to send an ambulance.
NHS in England
Oct 2025
P-004341 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr K complains about the delay in his wife, Mrs K, being seen by a doctor in the Emergency Department of the Trust in December 2023.
NHS in England
Partly Upheld
Nov 2025
P-004665 — An independent provider in the City of Derby …
The K's complain WMAS and 111 incorrectly categorised their mother's symptoms, 111 did not give an estimated time for ambulance arrival and the ambulance took too long to arrive. They also complain about aspects of WMAS's complaint responses.
NHS in England
Jan 2026
P-001103 — East of England Ambulance Service NHS Trust
Mr R complained that there was a delay in the Ambulance Trust sending an ambulance for Mrs R. He also complained about the care and treatment his wife received from the Hospital Trust at the end of her life.
NHS in England
Not Upheld
Aug 2021
P-003859 — East of England Ambulance Service NHS Trust
Ms A complains that on 9 and 10 April 2021 the Trust refused to take her father to hospital despite the severe pain he was in.
NHS in England
Not Upheld
Sep 2023
P-002251 — London Ambulance Service NHS Trust
Mr B complains the Trust told him to call 111 instead of 999. He then says the Trust agreed his wife needed an ambulance but there were delays with it arriving.
NHS in England
Oct 2023
P-002289 — North East Ambulance Service NHS Foundation Trust
Mrs A complains an ambulance crew failed to properly assess her condition and do the right tests, they should have taken to her to hospital and the complaint responses contain lies to cover up what the ambulance crew did.
NHS in England
Nov 2023
P-002425 — West Hertfordshire Hospitals NHS Trust
Mr T complains that when he went to the Emergency Department, staff did not clean his wounds or give him stitches. He says he waited seven hours before it discharged him home without any treatment apart from a tetanus injection.
NHS in England
Jan 2024
P-002452 — Countess of Chester Hospital NHS Foundation Trust
Mr O complains about the care he had at the Trust's emergency department. He says it made him wait for several hours before being admitted and staff ignored his concerns and request for help.
NHS in England
Feb 2024
P-002732 — ERS Medical
Mrs O complains about the service ERS Medical (ERS) provided to her mother, Mrs A, when they arrived to transport her to a hospital appointment on 10 December 2021.
NHS in England
Not Upheld
Jun 2024
P-002974 — A practice in the Cannock Chase area
Mr U complains that the Practice suggested he take his father home and ask a family member to take him to A&E instead of allowing them to wait there for an ambulance.
NHS in England
Sep 2024
P-003064 — A practice in the Gloucester area
Dr M complains about delays in a GP requesting an ambulance for his mother and delays in the ambulance arriving.
NHS in England
Oct 2024
P-003325 — Imperial College Healthcare NHS Trust
Mr A complains about the actions of three organisations during March 2023 when he had abdominal pain and vomiting. He complains the Practice did not diagnose the condition, the Trust made a wrong diagnosis and would not reassess him the next day, and the Ambulance Trust would not take him …
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