Ambulance handover delays have long been, and continue to be, a serious and significant issue across Wales, with many patients coming to avoidable harm as a result. At present, response times are approximately 50% longer for life threatening (Red) 999 calls than in 2019. For serious but not immediately life threatening (Amber) calls they are over 200% longer, on average.

Whilst there have been some recent changes in the way ambulance handover delays are monitored in Wales, with slight performance improvement in certain regions, significant changes still need to be made throughout the NHS in Wales to ensure compliance with handover targets and prevent harm.

Hugh James is routinely instructed in civil claims involving significant ambulance delays that often result in fatal outcomes for patients and frequently represent those families where such a delay has contributed to the death of a loved one.

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Inquest into death of Valerie Hill

In May 2025, Hugh James was instructed to represent the family of Mrs Valerie Hill throughout a three-week, Article 2 ECHR ‘Middleton’ inquest. The lengthy and complicated inquest covered not only the factual circumstances leading to Mrs Hill’s sad death, but also the overarching issues regarding ambulance delays in South Wales.

The inquest heard evidence that Mrs Hill, aged 89, fell in her room at her residential home on 7 March 2022. An ambulance was called promptly, with staff identifying a likely fractured femur and Mrs Hill being unable to move from the floor. Despite repeated calls to the Welsh Ambulance Service Trust throughout the day, by both staff and family members, paramedics did not arrive until more than 14 hours later.

During this prolonged period, Mrs Hill was left in significant pain, unable to move, and received only limited fluid intake. When she was finally admitted to Royal Glamorgan Hospital, surgery was delayed until the next day. Tragically, Mrs Hill’s condition deteriorated post-operatively, and she passed away on 11 March 2022.

Expert medical evidence presented during the inquest indicated that this period of a 14 hour “long lie” significantly contributed to her deterioration and reduced her chances of survival.

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Welsh Ambulance Handover Delays

Welsh Government monitor ambulance handover performance against the Welsh Health Circular 2016. This Guidance sets out expectations of Local Health Boards to deliver timely ambulance patient handover, with a target of 15 minutes for handovers from ambulance to hospital staff to take place.

The Welsh Health Circular was updated in 2024 and reiterates that the handover target of 15 minutes remains the standard across Wales, with delays over 60 minutes being noted as unacceptable, and should be exceptional.

During the inquest into Mrs Hill’s death, the Coroner’s concerns in relation to the ambulance delays were sadly not in isolation and were a long-standing issue in Wales. In recent years, Coroners across Wales have repeatedly issued Regulation 28 Prevention of Future Deaths reports to the Minister for Health and Social Services (now the First Minister of Wales, Eluned Morgan), the Chief Executive of the Welsh Ambulance Service and the Chief Executives of various Health Boards calling for action to be taken in respect of ambulance handover delays, and the impact upon vehicle response times to patients requiring urgent and emergency care in the community.

Notwithstanding the pressure for reform from Coroners, Health Boards have consistently been falling foul of the 15-minute target for many years, with delays often being in excess of a number of hours.

As a result of the persistent issues and concerns surrounding the ambulance handover delays, Senior Coroner, Mr Graeme Hughes, widened the scope of the inquest into the death of Mrs Hill to include a wider investigation into the potential systemic failures by Welsh Government and their contribution to the handover delays being seen. Given the Coroner’s concerns regarding the potential systemic failures, the inquest engaged Article 2 ECHR.

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Middleton Inquest

An Article 2 ECHR inquest, known as a ‘Middleton’ inquest, is more complex than a traditional ‘Jamieson’ inquest. A Jamieson inquest focuses specifically on the four statutory questions; who died, when did they die, where did they die and how, without exploring blame or potential wider systemic issues. Middleton inquests have a much wider scope and look to answer the four statutory questions alongside in what circumstances the deceased came about their death.

A Middleton inquest can explore systemic issues under Article 2 ECHR. This occurs when the state or its agents are involved, and where the state had a duty to protect life but has failed. Where the state has a systemic or substantive duty to protect life, this requires legislative and administrative framework to be put in place. Obligations arise in the public health sphere whereby hospitals must have adequate regulations in place in order to ensure compliance with this duty.

It has long been clear that there have been systemic issues within NHS Wales that have contributed to the delays in conveying acutely unwell patients to hospital, often resulting in devastating, avoidable outcomes. Mr Hughes was keen to establish what steps have been taken since March 2022 to improve the issues with hospital handovers and discharge delays, and to what extent further action is required.

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Inquest evidence and Prevention of Future Deaths (PFD) Reports

Evidence throughout the inquest heard that lack of flow throughout hospitals, discharge delays and issues with community and social care were all contributing factors to the ambulance handover delays seen across Wales, as well as the underfunding of the NHS.

It was heard that Cwm Taf Morgannwg University Health Board had been in targeted intervention since October 2022, with no significant change or performance improvement in relation to their compliance with the 15-minute handover target.

The inquest also heard from the Chief Executive Officer of the Welsh Ambulance Service. In July 2021, he wrote to the Director General Health and Social Service Group to formally document the substantial pressure the Welsh Ambulance Service were experiencing, and the patient harm that was occurring in the community as a result of the delays. The Chief Executive Officer called for a system-wide response to “a system-wide challenge” to free up ambulance availability to respond to patients in the community. It was heard that no response from the Welsh Government was forthcoming in this respect.

The previous Prevention of Future Deaths (PFD) reports issued by coroners across Wales, including within the preceding 12 months, were mainly in relation to timeliness of response. The inquest heard that the improvements made by the Welsh Ambulance Service, to include the introduction of rapid clinical screening, mental health response vehicle across Southeast Wales, and increased number of clinicians in clinical contact centres, have been insufficient to mitigate the serious challenges in service delivery attributed to continued challenges with “flow” across the health and care system.

At the conclusion of the inquest, the Coroner issued PFD reports to two parties: Merthyr Tydfil County Borough Council, in relation to the management of Mrs Hill’s falls risk, and Eluned Morgan, First Minister of Wales, with regard to the systemic issues surrounding ambulance handover delays affecting health boards across Wales.

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Welsh Ministers’ Response to the Regulation 28 Report and Present Position in Wales

In response to Mr Hughes’ Regulation 28 report, First Minister Eluned Morgan commented that she remains concerned about the level of ambulance patient handover delays at emergency departments, and the slow progress that has occurred to date in reducing such delays.  

A review of health board compliance with the Ambulance Patient Handover Guidance was completed in March 2025 by NHS Performance and Improvement, with a report containing learning and key themes for health boards to consider being shared by Welsh Government on 18 June 2025.
The report found that ambulance handover delays are predominately a symptom of system-wide issues and must be recognised as a system-wide responsibility.

Following publication of the report, Welsh Government have sought urgent assurance from each Health Board across Wales as to how they will deliver specific actions, as recommended by NHS Performance and Improvement, to support compliance with handover guidance, and work toward performance of handovers within 45 minutes.

The First Minister’s response also notes that, in light of the ongoing systemic issues and poor ambulance handover performance, the Cabinet Secretary for Health and Social Care has announced a ‘National Handover-45 Taskforce’ which aims to support Health Boards and the Welsh Ambulance Service Trust to deliver system-wide improvements to improve ambulance handover.

It is intended that the taskforce will develop and support delivery of high-impact clinical pathways in the community and support the delivery of effective evidence-based emergency department processes to improve the flow of patients from emergency departments to wards and optimise discharge.

Whilst the First Minister’s response to Mr Hughes’ Regulation 28 Report can be seen as promising,
the reality is that ambulance handover delays across Wales persist. At present, the majority of Health Boards across Wales are either in the highest or second highest level of escalation in respect of urgent and emergency care. On 3 January 2025, the Welsh Ambulance Service Trust also declared a business continuity incident due to the wider system pressures across Wales, with protracted handover delays at hospital sites and prolonged community delays along all categories of calls, risking patient safety.

It is clear that the severity, frequency and persistence of problems in relation to urgent and emergency care, namely ambulance handover delays, across Welsh Health Boards appears to exceed that which can be dealt with through routine arrangements. The failures identified throughout the inquest into Mrs Hill’s death were not individual errors, but a myriad of systemic failings relating to resources, staff, legislation, guidance and government policy.

To date, there has not been a large-scale, public inquiry into the ambulance delays seen in Wales. Whilst coroners and other local bodies are doing all that they can to address the ongoing issues, ultimately an in-depth public inquiry and overhaul of the NHS in Wales in its entirety is needed to affect the change that is required to improve patient safety.

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Importance of Specialist Inquest Representation

Specialist legal representation for families at an inquest is vital, particularly where the coroner’s investigation involves a public body or the circumstances are complex, as was the case in the inquest into the death of Mrs Hill.

NHS bodies will always have legal advisors instructed to represent them during inquests. Most hospitals have their own legal services team who regularly attend inquests with clinical staff. Unfortunately, there is no automatic right for a family to be afforded legal representation throughout an inquest.

Representation for the family is essential to allow equality of arms, and justice. Legal advisors enable families to fully understand the circumstances of the death, ask relevant questions of witnesses and ensure adequate and appropriate submissions are made to the coroner to allow for a fully informed investigation.

Hugh James Solicitors has a specialist inquest team, which forms part of the wider clinical negligence department, that offers advice and representation, with the aim of helping families better navigate the inquest process in already distressing and emotional circumstances.

There is a long way to go before urgent and emergency care in Wales returns to tolerable levels, and an improvement in patient safety within the community is seen. Sadly, families will inevitably continue to face the prospect of inquest proceedings in this regard, where a loved one may have died in connection with ambulance handover delays or poor emergency care.
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