“The 999 call to the ambulance service was received at 14.24 hours”
Dated 30 Jan 2025, from the coroner for Somerset. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 27 Mar 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated30 Jan 2025
- Deadline27 Mar 2025
- Published on judiciary.uk4 Feb 2025
- Today27 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Western Ambulance Service NHS Foundation Trust | Response publishedPublished on judiciary.uk in February 2025. |
The coroner’s concerns
a) The 999 call to the ambulance service was received at 14.24 hours. The Emergency Medical Dispatcher was informed that Mr Whiteley had fallen, had banged his head, was bleeding and was barely conscious. This generated a category 2 response requirement. b) At 15.03 hours there were 107 incidents awaiting allocation across the ambulance Trust area, including 21 in the Bravo patch where Mr Whiteley’s incident occurred. c) The excessive number of incidents awaiting allocation was caused by delays in handing over the care of patients from ambulance crews to the four main acute hospitals within the Bravo area (Musgrove Park Hospital, Weston General Hospital, Southmead Hospital and the Bristol Royal Infirmary). d) The handover delays meant that there were over 84 hours of ambulance time lost to handovers. This was the equivalent of approximately 7.5 double crewed ambulance shifts which were lost to delays. e) An ambulance was allocated to Mr Whitely at 16.08 hours with an expected time of arrival of 16.30 hours. Had it arrived, Mr Whiteley’s ambulance would have taken at least 2 hours and 6 minutes to arrive from the time of the 999 call. f) In the event, Avon and Somerset Police conveyed Mr Whiteley to hospital as the attending Police Tactical Medic was concerned about the ambulance delay and the need for timely assessment at hospital. This meant that the ambulance could be stood down. g) The evidence given by the ambulance Trust at the inquest was that the delays in allocating ambulances caused by the delays in handing over to acute hospitals is continuing.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0063
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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