Los Gatos City Council
August 11, 2026

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 2 with nearly all applicable existing objective development regulations the Project is subject to and allowing deviations from these standards would similarly result in a “specific adverse impact… upon public health and safety or the physical environment” pursuant to California Government Code Section 65915(d).

For the foregoing reasons and as further detailed below, we respectfully request that the Town Council deny this Project outright, or alternatively, direct Town staff to prepare an EIR in accordance with CEQA before it is considered for approval.

I. THERE IS A FAIR ARGUMENT SUPPORTED BY SUBSTANTIAL EVIDENCE IN THE

RECORD THAT THE PROJECT WILL RESULT IN SIGNFICANT ENVIRONMENTAL

IMPACTS, MANDATING PREPARATION OF AN EIR
Based on our review of the Initial Study and Mitigated Negative Declaration for the Project dated November 25, 2025 (“Original IS/MND”) and the Recirculated Initial Study and Mitigation Negative Declaration for the Project dated June, 2026 (“Recirculated IS/MND”) and additional evidence evidence in the record, and as explained in our earlier comment letter submitted on the Original IS/MND dated October 9, 2025 and appearing as Letter 23 on pages 148-190 of the Responses to Comments on the Original IS/MND (“2025 RTC”) and our comment letter on the Recirculated IS/MND dated May 18, 2026 and appearing as Letter 11 on pages 168- 169 of the Responses to Comments on the Recirculated IS/MND (“2026 RTC”), this Project cannot be approved unless an EIR is first prepared and certified in accordance with CEQA to ensure that the significant environmental impacts of this Project are fully disclosed, analyzed, and mitigated and a full range of alternatives to the Project are identified and analyzed.

Notably, an EIR was prepared for a smaller, prior version of this project in 2105 which was recirculated in 2017. The EIR was never certified because the Town Council voted unanimously to deny the applicant’s request to cancel the Williamson Act and thereby rejected the proposed project. There is no explanation in the IS/MND as to why the Town required an EIR for a smaller 10-lot version of this Project eight years ago and yet just eight years letter is now proceeding with only an IS/MND for this 12-lot Project on the very same project site. Common sense should dictate that if an EIR was required by the Town for a smaller project on the site, it should require an EIR for the current larger project which would have even more potential to result in significant environmental impacts. While this point was raised in our comments on the IS/MND, the IS/MND failed to address this.

A. Governing CEQA Law Requires an EIR When There is a Fair Argument Supported by Any Substantial Evidence in the Record that the Project May Result in a Significant Unmitigated Impact on the Environment The Project’s Builder’s Remedy status does not exempt it from complying with CEQA. (Cal. Gov.

Code, Sec. 65589.5(e).) An EIR is required whenever there is a “fair argument” that a project may have a significant effect on the environment despite identified mitigation measures —even if there is also substantial evidence in the record to the contrary. (See No Oil, Inc. v City of Los Angeles (1974) 13 Cal.3d 68, 75.) This fair-argument test is a very low threshold. (Laurel Heights Improvement Assoc. v. U.C. Regents (1993) 47 Cal.4th 376). A negative declaration or mitigated

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 3 negative declaration is authorized only when the lead agency (here, the Town) determines that (i) changes to the project or mitigation measures would mitigate any identified potentially significant adverse environmental effects of the project “to a point where clearly no significant effect on the environmental would occur” and (ii) no substantial evidence exists supporting a fair argument that the project will result in a significant environmental effect. (Cal. Pub. Res. Code, Sec. 21064.5; 14 Cal. Code Regs., Sec. 15063(c)(2) & 15070(b).) CEQA places the burden of environmental investigation not on the public but on the public agency. (See Sundstrom v County of Mendocino (1988) 202 Cal.App.3d 296, 311 [a public agency “should not be allowed to hide behind its own failure to gather relevant data”].) An IS/MND will be set aside if there is substantial evidence in the record that the mitigation measures imposed as conditions to its adoption are insufficient to mitigate the project’s impacts. (See California Native Plant Soc’y v County of El Dorado (2009) 170 Cal.App.4th 1026; Citizens for Responsible & Open Gov’t v City of Grand Terrace (200) 160 Cal.App.4th 1323, 1340.) Where experts have presented conflicting evidence on the extent of the environmental impacts of a project, as is the case here, a city must consider the impacts to be significant and prepare an EIR. (Pocket Protectors v. Sacramento (2004) 124 Cal.App.4th 903, 935; Sierra Club v. County of Sonoma (1992) 6 Cal.App.4th 1307, 1317-1318; CEQA Guidelines, Sec. 15064(f)(5).) “It is the function of an EIR not a negative declaration, to resolve conflicting claims, based on substantial evidence, as to the environmental effects of a project.” (Pocket Protectors, supra, 25 Cal. App.4th at p 935). In the context of reviewing a negative declaration “neither the lead agency nor a court may ‘weigh’ conflicting substantial evidence to determine whether an EIR must be prepared in the first instance (Ibid.) Where such substantial evidence is presented, “evidence to the contrary is not sufficient to support a decision to dispense with preparation of an EIR and adopt a negative declaration, because it could be ‘fairly argued’ that the project might have a significant environmental impact.” (Sundstrom v. County of Mendocino (1988) 202 Cal.App.3d 296, 310).

B. Substantial Evidence in the Record Supports Fair Argument that the Project Will Result in Unmitigated Environmental Impacts
The San Francisco Bay Regional Water Quality Control Board submitted two letters into the record (2025 RTC pp. 3-6 and 2026 RTC, pp 8-11) which constitute substantial evidence supporting a fair argument that the Project’s significant impacts to the ephemeral creek channel, which are jurisdictional waters of the State, will not be mitigated to a less than significant level and therefore an EIR is required because the subsequent required permits are not mitigation measures and the proposed 1:1 mitigation ratio is unverifiable and likely infeasible. See also the letter submitted from the Sierra Club Loma Prieta Chapter and the Santa Clara County Bird Alliance (2026 RTC, pp. 16-22).

The Sierra Club Loma Prieta Chapter and the Santa Clara County Bird Alliance also submitted two letters into the record (dated October 17, 2025 and May 18, 2026 respectively) which constitute substantial evidence supporting a fair argument that the Project may result in the following unmitigated significant environmental impacts:

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 4 • The Project may result in unmitigated significant environmental impacts to the ephemeral creek channel, which are jurisdictional waters of the State (for the same reasons stated by the San Francisco Bay Regional Water Quality Control Board above). • The Project may result in unmitigated significant environmental impact to biological resources because:
o The Project may adversely impact wildlife corridor movements and result in cumulative habitat fragmentation.
o The Project is inconsistent with the Town’s General Plan policies protecting hillside habitat connectivity.
o The cumulative loss of hillside woodland and corridor function is not analyzed o The IS/MND improperly eliminates analysis of the Project’s impact on Crotch’s Bumble Bee which is a candidate endangered species entitled to protection during its candidacy period.
o The IS/MND fails to analyze the impact of introduced invasive species in the Ross Creek Watershed.
o The IS/MND fails to analyze the impact of introduced lighting on biological resources.
o The IS/MND fails to analyze bird-glass collision risk or mitigate for this risk as required by the Town’s General Plan.

As evidenced in the third-party peer review of the Biological Evaluation Report for 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California, Prepared By Live Oak Associates, INC (May 2025) this law firm commissioned from Patrick Kobernus, Principal Biologist of Coast Ridge Ecology, Inc. (attached hereto and incorporated herein as Exhibit B, and also attached to our December 15, 2025 letter to the Planning Commission) the IS/ MND’s conclusion that Project impacts on biological resources will be less than significant are not supported by substantial evidence in the record for the following reasons:
(1) It relies on an outdated floristic survey that is over 14 years old; (2) It fails to address sensitive plant communities potentially present on the project site in accordance with California Department of Fish & Wildlife (CDFW) protocols; (3) Mitigation Measure 3.3.5a for the Project’s impact on Burrowing Owls is inadequate because it does not specify methodology and timing of the pre-construction surveys; (4) It fails to identify potential impacts to special status amphibian and reptile species and mitigate for these impacts;

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 5 (5) It fails to include a habitat assessment of the project site for bats as part of the IS/ MND and the preconstruction surveys required by Mitigation Measure 3.3.6a to address the Project’s impact on bats is inadequate;
(6) It fails to include a detailed survey and mapping of active woodrat middens and a woodrat relocation plan;
(7) It fails to identify potential impacts on the western bumble bee, (Bombus occidentalis); and Crotch’s bumble bee, (Bombus crotchii) and mitigate for these impacts; and (8) Its conclusion that there would be no impact to wildlife corridors is unsupported by the record and it fails to mitigate for these potential impacts.

As explained in our October 9, 2025 and May 18, 2026 comment letters on the Original IS/MND and the Recirculated IS/MND and as further supported by substantial evidence submitted into the record including, there is a fair argument that the project may result in the following significant unmitigated impacts on the environment:
• The Project may result in a significant unmitigated impact on Aesthetics because:
o It conflicts with most of the Town’s Hillside Development Standards and Guidelines, including grading and height standards, which were adopted for the purpose of protecting scenic quality.
o It will create a new source of substantial light or glare, and contrary to the statements in the IS/MND (at pp. pp. 28-29), the Town cannot rely on the Project’s compliance with its Hillside Design Standards and Guidelines outdoor lighting standards to mitigate this impact because, as the IS/MND itself states earlier in the document (at p. 7), “[b]ecause the project is subject to Builder’s Remedy, compliance with all of the Town’s guidelines, policies, or programs is not required ...” o The IS/ MND conclusion that “the majority of the project site would remain screened by the existing trees and vegetation” is unsupported because there is no enforcement mechanism to ensure the continued existence and maintenance of these trees and vegetation since as acknowledged in the IS/MND, the Project is not subject to a deed restriction to ensure this which would have otherwise been required by the Hillside Development Standards and Guidelines because it is a Builder’s Remedy Project (See 2025 RTC, p. 192.)
• The Project may result in a significant unmitigated impact on Biological Resources because:
o It will remove 223 protected oak trees yet it will replace only 85 of these trees onsite which is just 15% of the 551 replacement trees required by the Town’s Tree Protection Ordinance to mitigate for the loss of these trees. While payment of an inlieu fee is proposed as substitute mitigation for the remaining 85% of the tree replacement obligation (Mitigation Measure IV-9), payment of this fee is inadequate mitigation under CEQA because the effectiveness of the fee program itself has

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 6 not been examined under CEQA (California Native Plant Soc’y v County of El Dorado (2009) 170 CA4th 1026), the amount of the in-lieu fee is not specified and may not even be required depending on whether the removed tree it is associated with is removed “to implement or maintain Defensible Space” which in turn appears also to be discretionary, it is unclear how or when the in-lieu fee will be paid, administered and applied to appropriately mitigate the loss of oak woodland and the individual 223 protected trees lost. Accordingly, Mitigation Measure IV-9 is inadequate to mitigate the loss of the 223 protected trees. o The IS/MND fails to consider, much less mitigate for, additional oaks that may be lost or harmed as a result of the subdivision improvements and it does not does analyze or even acknowledge that the loss of the oak woodland habitat on the Project site as a whole interdependent community of organisms would be a significant impact and mitigate for this loss. As explained in the August 28, 2025 letter submitted by the California Department of Fish and Wildlife (CDFW) on another project (included as Attachment 1 to our Ocrtober 9, 2025 letter commenting on the IS/MND), the CDFW considers oak woodlands as a sensitive natural community that supports a host of wildlife and takes the position that impacts to this natural community should be appropriately mitigated for. As explained and substantiated in our October 9, 2025 letter, Oak woodlands are some of the richest overall wildlife habitats in California, and rank among the top three habitats for birds yet they are increasingly diminishing due to fire suppression, overgrazing, urban development, and disease. • The Project may result in significant unmitigated Land Use and Planning Impacts because:
o The IS/MND does not even identify what land use plans, policies, and regulations were adopted for the purpose of avoiding or mitigating an environmental effect, let alone conduct the required consistency analysis to determine whether there is a conflict between the Project and these plans, policies and regulations. Notably the IS/MND concludes that the Project would not conflict with “some” of the standards of the Hillside Specific Plan without identifying which of those standards the Project does conflict with and explaining why those standards were not adopted for the purpose of avoiding or mitigating an environmental effect. Given that IS/MND itself acknowledges that the Project would conflict with standards set forth in the Hillside Specific Plan which was adopted for the purpose of protecting the Town’s hillsides, and the Tree Ordinance, which was adopted for the purposes of protecting trees, substantial evidence supports a fair argument that the Project would result in a potentially significant land use and planning impact and an EIR must be prepared. o The IS/MND also fails to address the Project’s impact on street intersection levels of services (“LOS”) as required by the General Plan. While we acknowledge that transportation impacts under CEQA are now evaluated from VMT (vehicle miles traveled) as opposed to LOS, the Project’s impact on LOS is critical to evaluating its impact on emergency access and wildfire evacuation (and in turn, its impact on wildfires), and this analysis is glaringly missing. Moreover, a LOS analysis is

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 7 required by the Town’s 2040 General Plan to determine whether improvements are needed to ensure that LOS will remain at an acceptable level consistent with the below General Plan policies:
▪ MOB-10.2 Level of Service. If a project will cause the current LOS for any project affected intersection to drop by more than one level for an intersection currently at LOS A, B, or C, or to drop at all if the intersection is at LOS D or below, the project shall construct improvements and/or put TDM measures in place, as directed by the Town Engineer, so that the operation will remain at an acceptable level. These measures shall be implemented and maintained as a condition of approval of the project.
▪ MOB-12.1 Hillside Emergency Vehicle Access. Establish and maintain a hillside road pattern that provides adequate access for residents and emergency vehicles in both normal and emergency situations without introducing new through access roads that would invite unwanted traffic into the area, induce further development, or threaten plant or animal habitats or migration patterns.
▪ HAZ-3.4 Development Restrictions. Restrict development in areas with inadequate water flow or emergency access.
▪ PFS-20.2 Fire Hazard Mitigation in Project Review. Identify and mitigate fire hazards during the project review and approval process.

Based on our review of the record, it is apparent that substantial evidence supports a fair argument that the Project may have a significant unmitigated impact on the environment. The Town’s environmental consultant’s responses do not invalidate the substantial evidence presented by the comment letters that significant environmental impacts will result from the Project. Where, as here, there is conflicting evidence of the environmental impacts in the record, the Town must consider the impacts to be significant and prepare an EIR before it can approve the Project. (See Pocket Protectors, supra, 124 Cal.App.4th at p. 935; see Sierra Club, supra, 6 Cal.App.4th at pp. 1317-1318; see CEQA Guidelines, Sec. 15064(f)(5).) II. THE PROJECT WOULD RESULT IN SPECIFIC, ADVERSE IMPACTS UPON PUBLIC

HEALTH AND SAFETY
We recognize that the Town cannot reject the Project outright unless it can make certain denial findings, one of which is that the project “as proposed would have a specific, adverse impact upon the public health or safety, and there is no feasible method to satisfactorily mitigate or avoid the specific, adverse impact without rendering the development unaffordable to low- and moderateincome households.” (Cal. Gov. Code, Sec. 65589.5(d)(2).) The Project meets this denial finding because it would: (1) impede the surrounding neighborhood’s evacuation and emergency access and delay travel time to the nearest hospital; (2) increase erosion and landslide risk on the Project site and its vicinity; and (3) dramatically increase stormwater runoff and peak flows exposing the

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 8 surrounding area to risk of flooding and water quality degradation. Accordingly, the Project should be denied.

A. The Project Would Impede Evacuations and Emergency Access and Delay Travel Time to the Nearest Hospital
Increased traffic congestion can severely threaten public health and safety by delaying ambulance response times, obstructing hospital access routes, and creating dangerous bottlenecks during emergency evacuations. The 113 new daily vehicle trips estimated to be added by the Project will further congest surrounding roads and intersections that are already subject to gridlock especially during drop off and pick up at Hillbrook School just 0.2 miles away, as well as at Blossom Hill Elementary School (0.7 miles away), and Raymond J. Fisher Middle School (1.0 miles away).

This resulting congestion would delay and impede emergency access and fire evacuations, thereby exceeding established standards for emergency response and evacuation times and travel time to hospitals. As explained further below, this is a health and safety impact that justifies denial of the project.

The Santa Clara County Fire Department provides emergency response services to the residents of the Town of Los Gatos, including emergency response for fire suppression and rescue and emergency medical services. See: https://www.losgatosca.gov/3053/Fire-Services. As stated on its website (https://www.sccfd.org/emergency-response-overview/fire-suppression-rescue/) the Santa Clara County Fire Department’s standard for response is to “arrive at the scene of emergencies within five minutes of receipt of alarm, at least 90 percent of the time” The nearest fire station to the Project site is the Shannon Fire Station, located at 16565 Shannon Road, Los Gatos, CA 95032, which is approximately 1.2-1.4 miles away depending on the route.

According to Google Maps and as shown on Exhibit C, the travel time from the Shannon Fire Station to the Project Site is already 6 minutes during school drop off and pick up times which exceeds the Santa Clara County Fire Department’s standards.

The nearest full-service hospital to the Project Site is El Camino Health - Los Gatos Hospital, located at 815 Pollard Rd, which is approximately 5.6 – 6.2 miles away depending on the route.

According to Google Maps and as shown on Exhibit C, the travel time from the Project Site to the Hospital is already 12 to 24 minutes during school drop off and pick up times. California Code of

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 9 Regulations 10 Section 2240.1 et seq. requires health insurance networks to include a primary care provider within a maximum travel time of 30 minutes of an enrollee’s residence and a network hospital within 30 minutes of a covered person’s residence. The additional 113 daily trips generated by the Project could easily cause a more than 6 minute delay to the hospital, thereby exceeding this 30 minute standard.

Travel time is particularly important for life-threatening injuries, where a few short minutes can mean the difference between life and death. Studies show that travel time matters for severe injuries and that rural patients are more likely to die from traumatic injury than urban patients.

Even for non-life-threatening conditions, the barrier presented by travel time can lead individuals to delay care until the illness or injury is more severe, in some cases, limiting the effectiveness of treatment. Longer travel distance or travel time is also associated with more medical resource utilization, higher hospital admission rates, and greater mortality risks in some emergency situations. See Exhibits D, E , F and G.

As corrected in the Recirculated IS/MND, the Project site is located in a Very High Fire Hazard Severity Zone. According to the USDA Forest Service, the Town’s wildfire risk is 93% higher than other communities in the United States. (Wildfire Risk to Communities, retrieved from https://apps.wildfirerisk.org/explore/overview/06/06085/0600044112 last visited August 3, 2026).) The increased fire risk is due, in part, to the location of the Town, which wraps around the mouth of Los Gatos Creek Canyon where the Santa Cruz Mountains drop into the valley floor. What makes the Town different from neighboring cities is the reservoir corridor itself, which acts as a natural fire highway that channels wind and flame directly toward the Town. It has burned before.

The 1985 Lexington Fire consumed 13,000 acres above Lexington Reservoir and destroyed 42 homes in neighborhoods that still exist today; and during the 2020 CZU fire, embers landed on properties along Bear Creek Road and upper Highland Avenue. The risk of wildfire in the Town and at the Project site is very real.

The IS/MND concludes that the Project will not physically interfere with the Town’s emergency evacuation routes because it would not result in any substantial modifications to the existing roadway system. However, the IS/MND fails to acknowledge that – or even evaluate how - the additional trips generated by this 12-unit project (which exceed vehicle miles traveled (“VMT”) thresholds by generating 113 new daily trips not including construction generated trips) will impact the narrow, winding access roads to the Project site. (2026 RTC, p. 103.) These access roads already experience significant delay and gridlock from trips associated with the existing 70+ homes in the area together with school and beach traffic. (2026 RTC, pp. 77-78) If the proposed 12-unit project is built at the Project site, the traffic burden on surrounding neighborhood roads will increase, thereby restricting emergency access and evacuation routes for residents within the vicinity of the Project site in the event of a wildfire or other emergency. (Ibid.) While the IS/MND proposes an emergency vehicular access route from the Project site to Brooke Acres Drive, this route is intended to be used as an additional point of access for emergency response vehicles only—not as an evacuation route for the surrounding community in the event of a wildfire emergency. (See 2026 RTC, p. 110.) Therefore, the conclusion that this Project will have no impact on emergency evacuation and response is unsupported.

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 10 As acknowledged in the IS/MND, the Project will generate approximately 113 trips per day on top of the existing 799 daily trips associated with Hillbrook School, which is located near the Project site’s northwestern corner—a increase of over 14%. (Recirculated IS/MND, p. 189.) This increased traffic will undoubtedly degrade surrounding intersections thereby delaying emergency access and evacuations, creating a serious, adverse impact to public health and safety, especially in light of the severe risk of fire discussed above.

The Town Council should follow the lead of the City Council for the City of Saratoga, who denied a similar project, Masson Estates, on Pierce Road near the intersection of Saratoga Heights Drive on this ground on July 8, 2026, reasoning that the environmental impacts related to emergency access, response, and evacuation outweighed the anticipated housing benefits. Because this Project will further congest access roads that are already subject to gridlock which in turn will further exceed the response time standard established by the Santa Clara County Fire Department and exceed the travel time standard to hospitals established by State law, there is no feasible method to mitigate this adverse public health and safety impact of the Project without denying or reducing the density of the Project and therefore denial of the Project is justified.

B. The Project Would Increase Erosion and Landslide Risk.

The Project site sits within a County Landslide Hazard Zone with landslide, liquefaction, compressible-soil, and fault-rupture hazards. (IS/MND, pp. 66, 68.) Instead of mitigating these public safety risks, the Project applicant seeks multiple waivers to the Town’s Hillside Development Standards and Guidelines which were designed to safeguard the public from these risks. Specifically, the applicant seeks waivers to exceed the maximum allowable grading, thereby undermining slope stability and increasing the likelihood of landslides and erosion in this landslide hazard zone. (See 2026 RTC, pp. 70-72). While the IS/MND proposes to incorporate the recommendations from the geotechnical, geophysical, and hydrogeological investigation, the recommendations would not mitigate this risk. (See 2026 RTC, pp. 107-108.) The recommendations confusingly state that “compliance … would ensure the earthwork activities associated with the proposed [P]roject would be acceptable and would lead to instability” which appears to be a contradiction in terms. (Id.) Because the Project as proposed seeks waivers to the Town’s Hillside Development Standards and Guidelines and the Project is not subject to these Standards and Guidelines because it is a Builder’s Remedy Project, the health and safety impacts from this increased erosion and landslide risk cannot be feasibly mitigated without denying or reducing the density of the Project and therefore justifies denial of the Project.

C. The Project Would Increase Flooding Risk.

The Original IS/ MND stated that the Project would create an additional 62,224 square feet of impervious surface. As explained in the 2026 RTC, this was a calculation error which was corrected in the Recirculated IS/MND to acknowledge that the Project will create an additional 97,386 square feet of impervious surface, thereby dramatically increasing stormwater runoff and peak flows. (2026 RTC, pp. 32-97, 156.) Despite this risk, a final erosion-and-sediment control plan has not been prepared, leaving the surrounding area exposed to flooding, topsoil removal, water quality degradation, and the potential failure of the proposed bioretention pond adjacent to

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 11 Hillbrook School and nearby homes which is a public health and safety risk. (2026 RTC, pp. 32-

97.)
The IS/MND proposes to mitigate this risk by constructing a bioretention pond and storm drainage system “designed to capture, slow down, treat, and control stormwater runoff before the runoff leaves the site” through the backyards of several of the lots within the Project that will eventually be sold to independent owners. (2026 RTC, p. 152.) However, this identified mitigation does not ensure that the storm drainage system will be adequately maintained to prevent it from clogging or otherwise failing. Because the proposed storm drainage system will be constructed through the backyards of private property, and because neither the Project nor the IS/MND has proposed any mechanism for ensuring that those private property owners conduct the recurring maintenance necessary to ensure that the storm drainage system is operable, the health and safety risks that will result from flooding, topsoil removal, water quality degradation, and failure of the bioretention pond has not been adequately mitigated. Moreover, the proposed retention pond creates a serious risk of mosquito and vector-borne diseases. (2026 RTC, p. 117.) These adverse health and safety impacts caused by adding 97,386 square feet of impervious surface and the resulting health and safety impacts caused by the identified mitigation (a bioretention pond and storm drainage system with no assurance that they will be maintained), cannot be feasibly mitigated without denying or reducing the density of the Project and therefore justifies denial of the Project.

III. THE PROJECT DEVIATES FROM APPLICABLE OBJECTIVE DEVELOPMENT

STANDARDS AND SUCH DEVIATION WOULD RESULT IN SPECIFIC ADVERSE

PUBLIC HEALTH AND SAFETY IMPACTS
While we recognize that Builder's Remedy projects are not required to obtain Zoning and General Plan amendments, Builder’s Remedy projects must nonetheless comply with objective development standards pursuant to California Government Code Section 65589.5(f). The Project egregiously fails to comply with nearly all such standards, most of which were designed to protect public health and safety.

The Project as proposed exceeds the following standards applicable to Resource Conservation zoned properties such as the Project site : (i) the permissible density of principal residential units per lot, (ii) the minimum 20-acre lot area; (iii) maximum permitted height; (iv); maximum floor area; (iv) the minimum front, side, and rear setbacks (See Town Municipal Code, Sec. 29.49.160, 29.40.170, & 29.40.170; Staff Technical Review dated October 27, 2025, p. 6 (“2025 Staff Technical Review”).

The Project also conflicts with the Hillside Development Standards and Guidelines that apply to the Project site which is in the Hillside Specific Plan Area. Specifically, the Project proposes to build outside the Least Restrictive Development Area and on slopes greater than 30%, in violation of the hillside siting and slope constraints intended to limit grading and avoid hazard areas. (See 2025 Staff Technical Review, p. 6) The Project also conflicts with driveway and parking requirements of the Hillside Specific Plan, conflicts with the Below Market Price Housing Program because it does not meet the standards for the size and location of affordable units, and conflicts with the prohibition against swimming pools

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 12 on lots with slopes greater than 30%. (See id.) Moreover, the Project does not comply with minimum roadway width for fire access, and removes 223 protected trees, replanting only 85 trees on site when 551 replacement trees are required.

The applicant is requesting deviations from these requirements as “concessions and incentives” under State Density Bonus law. However, the Town may decline to grant this request under California Government Code Section 65915(d) if the concession or incentive would result in a “specific adverse impact . . . upon public health and safety or the physical environment which cannot be feasibly mitigated without rendering the development unaffordable to low-income and moderate-income households. As discussed above, granting many of these requested concessions and incentives would result in a specific adverse impact upon health and safety and the physical environment which cannot be feasibly mitigated without rendering the development unaffordable. Accordingly, the requested waivers and concessions should be denied along with the Project.

V. CONCLUSION
We respectfully request that the Town Council deny the Project on the following grounds: (1) there is a fair argument based on substantial evidence in the record that the Project will result in significant unmitigated environmental impacts, and, therefore, an Environmental Impact Report (“EIR”) is required before the Project can be approved; (2) the Project would result in a specific, adverse impact upon the public health or safety pursuant to California Government Code Section 65589.5(d); and (3) the Project conflicts with nearly all applicable existing objective development regulations the Project is subject to and allowing deviations from these standards would similarly result in a “specific adverse impact… upon public health and safety or the physical environment” pursuant to California Government Code Section 65915(d).

Sincerely,
Camas J. Steinmetz, Esq.

Cc: Gabrielle Whelen, Town Attorney
Joel Paulson, Community Development Director
Sean Mullin, Planning Manager
Client
Enclosures: Exhibit A: Vesting Tentative Map Excerpt Showing Proximity of Jon Witkin Property
Exhibit B: Biological Evaluation Report for the Project Prepared by Live Oak Associates, INC
Exhibit C: Travel Times to Nearest Fire Station and Hospital Exhibit D: Longer Emergency Care Travel Times Increase Presentation Complexity, Resource Use

ITEM NO. 1.

JSMF August 6, 2026 178 Twin Oaks Surrey Farms Project Letter to City Council 13 Exhibit E: The relationship between distance to hospital and patient mortality in emergencies: an observational study
Exhibit F: Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas
Exhibit G: The Silent Delay: How Traffic Congestion Kills Emergency Patients

ITEM NO. 1.

Exhibit A
Project Vesting Tentative Map Excerpt

ITEM NO. 1.

December 8, 2025
Camas J. Steinmetz, Esq.

Jorgenson, Siegel, McClure & Flegel, LLP
1100 Alma Street, Suite 210
Menlo Park, CA 94025
Subject: Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California.

Dear Ms. Steinmetz:

This letter documents the results of a third party peer review of the Biological Evaluation Report for 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California, Prepared By Live Oak Associates, INC (May 2025). The biological report evaluated the biological resources of a 17.55-acre property (APN 532-16-006) in Los Gatos, California (Project Site). The Project Site is located in an undeveloped hillside area between Cerro Vista Drive on the east, and Twin Oaks Drive on the west, within a residential area of Los Gatos, California.

This peer review consisted of a site visit to view the property from surrounding roads/parcels, and a review of the Biological Resource Evaluation (biological report). Additional documents and natural resource information reviewed as part of this peer review included the following sources:
• Biological Evaluation Report for 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California, Prepared By Live Oak Associates, INC (May 23, 2025). • Certified Arborist Report, Tree Preservation Plan Project #4185.10, December 15, 2024. Revision 3, Surrey Farms, Los Gatos, CA 95032, APN: 532-16-006. Prepared by Michael Gladden, ISA Certified Arborist #WE-2205A, McClintock Landscape Horticultural Services. • Surrey Farms Estates Subdivision Project Initial Study/Mitigated Negative Declaration, City of Los Gatos (September 2025).
• California Natural Diversity Database (CNDDB)
• California Native Plant Society (CNPS) Rare Plant Inventory • National Wetlands Inventory
• California Natural Community List (updated Feb 27, 2025) • CDFW Special Animals List (updated October 2025)
Project Description
The Project Site is a 17.55-acre area that consists primarily of grasslands and oak woodlands with some riparian (streamside) habitats. Existing single-family residences are located in the vicinity of the project site, as well as an existing private school located to the north of the site. The Surrey Farms Estates Subdivision Project (proposed project) would subdivide the project site into 12 residential lots, ranging in size from approximately 0.1-acre to 5.48 acres. The eastern portion of the project site would remain undeveloped. The western slope would be developed with 11 residences, comprised of eight market-rate single family residences and three below market-rate detached row houses. An additional single family

ITEM NO. 1.

Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

residence would be developed on the hillside’s northeastern slope. Access to the project site would be provided through a new private driveway off of Twin Oaks Drive west of the project site, as well as a separate access route to Lot 10 from Cerro Vista Court. 1 1) Plant Communities and Rare Plants
Rare Plants
The biological report concluded that there are two rare plant species that have the potential to occur on site: Santa Clara red ribbons (Clarkia concinna ssp. automixa) and bent flowered fiddleneck (Amsinckia lunaris). The report also determined that both of these species were absent based on a floristic survey of the property conducted in 2012 by Wood Biological. As of 2026, the floristic survey would be 14 years old, and an updated floristic survey of the property should be conducted. Most biological reports need to be updated approximately every 5 years, depending on the site, and for habitats dominated by long-lived perennial plants, such as forests, surveys that were not conducted within the previous five years may not adequately represent the current baseline conditions and should be re-conducted (CDFW 2018) 2 .

Plant Communities
The biological report lists Mixed Oak Woodland as present on site, which is not considered a Sensitive Plant Community by CDFW. However, there are multiple species of oak trees and sycamores on site that may be considered sensitive communities by CDFW.

There are 204 Valley Oak (Quercus lobata) trees on site. Valley Oak woodland is considered a sensitive natural community under CEQA due to its S3 rank3. The California Department of Fish and Wildlife maintains a list of Sensitive Natural Communities. Natural Communities with ranks of S1-S3 are considered Sensitive Natural Communities to be addressed in the environmental review processes of CEQA and its equivalents. For alliances with State ranks of S1-S3, all associations within them are also considered Sensitive.

Based on the tree species identified in the arborist report (McClintock Landscape Horticultural Services, 2024)
4 , the following sensitive plant communities are potentially present on the project site (shown below).

There are five plant community associations within two Valley oak Alliances, which are considered Sensitive by CDFW (shown below).
1 Surrey Farms Estates Subdivision Project Initial Study/Mitigated Negative Declaration, September 2025. https://www.losgatosca.gov/DocumentCenter/Index/2227
2 Protocols for Surveying and Evaluating Impacts to Special Status Native Plant Populations and Sensitive Natural Communities. State Of California, California Natural Resources Agency, Department of Fish and Wildlife March 20, 2018.
https://nrm.dfg.ca.gov/FileHandler.ashx?DocumentID=18959#:~:text=Use%20of%20Existing%20Surveys&text=H abitats%2C%20such%20as%20grasslands%20or,and%20should%20be%20re%2Dconducted. 3 State (S) and Global (G) rarity ranks are indicated for Alliances and some Associations; those with ranks of 1-3 are considered Sensitive. California Natural Community List https://wildlife.ca.gov/Data/VegCAMP/NaturalCommunities#sensitive 4 Certified Arborist Report, Tree Preservation Plan Project #4185.10, December 15, 2024. Revision 3, Surrey Farms, Los Gatos, CA 95032, APN: 532-16-006. Prepared by Michael Gladden, ISA Certified Arborist #WE-2205A, McClintock Landscape Horticultural Services.

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Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

71.035.00 Valley oak woodland and forest (Alliance) G3 S3

71.040.05 Quercus lobata / grass - Sensitive

71.040.06 Quercus lobata – Quercus agrifolia / grass - Sensitive

71.040.18 Quercus lobata – Quercus douglasii - Sensitive

71.040.23 Quercus lobata / Baccharis pilularis – Diplacus aurantiacus - Sensitive

71.045.00 Valley oak riparian forest and woodland (Alliance) G3 S3

71.045.01 Quercus lobata – Quercus agrifolia / Toxicodendron diversilobum – (Symphoricarpos ssp.) There are six California sycamore trees identified on site, and almost all of which are large diameter trees.

The California Sycamore – Coast Live Oak Woodland Alliance has six plant community associations that are considered Sensitive by CDFW (shown below).

61.310.00 California sycamore – coast live oak woodlands G3 S3

61.310.02 Platanus racemosa – Aesculus californica – Sensitive

61.311.02 Platanus racemosa – Bromus hordeaceus – Sensitive

61.311.03 Platanus racemosa – Annual grass – Sensitive

61.312.01 Platanus racemosa – Quercus agrifolia - Sensitive

61.313.02 Platanus racemosa – Toxicodendron diversilobum – Sensitive

61.313.08 Platanus racemosa – Quercus lobata - Sensitive Recommendation for Plant Communities and Rare Plants
An updated floristic survey of the project area should be conducted by a Qualified Botanist(s) that includes an evaluation for both rare plants and sensitive plant communities, following the CDFW 2018 protocols (CDFW 2018).
2) Burrowing Owls
Mitigation Measure 3.3.5a (Pre-construction Surveys) in the biological report states that “A qualified biologist would conduct a preconstruction survey for burrowing owls following the 2012 CDFW Guidelines or most recent guidelines, which includes two surveys, one within 14 days prior to the start of construction and the second within 24 hours prior to the start of construction.” The bio report does not provide any additional information on what the 2012 CDFW Guidelines5, actually require for the survey and this information should have been included in the mitigation measure. In the 2012 CDFW Guidelines, preconstruction surveys are described as “Take Avoidance Surveys”. Take Avoidance Surveys are to be conducted using the same methods described for detection surveys in the 2012 CDFW Guidelines, and have very specific methods, and should not be confused with general preconstruction surveys.

Recommendation for Burrowing Owls
Surveys for Burrowing Owls should be conducted according to the CDFW 2012 Guidelines. The method and timing for these surveys from the 2012 Guidelines is provided below:

Survey method. Rosenberg et al. (2007) confirmed walking line transects were most effective in smaller habitat patches. Conduct surveys in all portions of the project site that were identified in the Habitat Assessment and fit the description of habitat in Appendix A. Conduct surveys by walking straight-line 5 Staff Report on Burrowing Owl Mitigation State of California Natural Resources Agency Department of Fish and Game March 7, 2012. https://nrm.dfg.ca.gov/FileHandler.ashx?DocumentID=83843&inline

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Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

transects spaced 7 m to 20 m apart, adjusting for vegetation height and density (Rosenberg et al. 2007).

At the start of each transect and, at least, every 100 m, scan the entire visible project area for burrowing owls using binoculars. During walking surveys, record all potential burrows used by burrowing owls as determined by the presence of one or more burrowing owls, pellets, prey remains, whitewash, or decoration. Some burrowing owls may be detected by their calls, so observers should also listen for burrowing owls while conducting the survey. Care should be taken to minimize disturbance near occupied burrows during all seasons and not to “flush” burrowing owls especially if predators are present to reduce any potential for needless energy expenditure or burrowing owl mortality. Burrowing owls may flush if approached by pedestrians within 50 m (Conway et al. 2003). If raptors or other predators are present that may suppress burrowing owl activity, return at another time or later date for a follow-up survey.

Weather conditions. Poor weather may affect the surveyor’s ability to detect burrowing owls, therefore, avoid conducting surveys when wind speed is >20 km/hr, and there is precipitation or dense fog. Surveys have greater detection probability if conducted when ambient temperatures are >20º C, <12 km/hr winds, and cloud cover is <75% (Conway et al. 2008).

Time of day. Daily timing of surveys varies according to the literature, latitude, and survey method.

However, surveys between morning civil twilight and 10:00 AM and two hours before sunset until evening civil twilight provide the highest detection probabilities (Barclay pers. comm. 2012, Conway et al. 2008). 3) Special Status Amphibians and Reptiles
The biological report provides determinations (in Table 2B: Special Status Species that Could Occur In the Project Vicinity) that the following special status amphibian and reptile species are absent from the site: Santa Cruz black salamander (Aneides niger), California tiger salamander (Ambystoma californiense), Foothill yellow-legged frog (Rana boylii), California giant salamander (Dicamptodon ensatus), and northwestern pond turtle (Actinemys marmorata), based on lack of suitable (primarily aquatic) habitat. However many of these species use uplands during part of their life cycle, including habitats such as oak woodlands and grasslands that are found on the project site. Also several of these species have been shown to move long distances through upland habitats (in some cases several hundred feet or more), and residing within upland habitats for several months at a time.

In addition, while the report states that the federally listed California red-legged frog (Rana draytonii) may use Ross Creek as a movement corridor, the included mitigation measure (Mitigation Measure 3.3.4a), requires preconstruction surveys for this species limited to within 50 feet of Ross Creek. This species has been documented to move up to 2 miles from aquatic habitats during dispersal/movement events, and they are known to move through all types of upland terrain and slopes, including the types of habitat present on the project site (Bulger, 1999).
6 Recommendation for Special Status Amphibian and Reptiles To determine that a species is absent on a given site, when there is some potential habitat to support the species, requires field surveys by Qualified Biologist(s) to determine presence or absence. While there may be a low likelihood that each of these special status species occurs on the project site, the size of the site (17.55 acres) is substantial, and is partially connected to open space habitats to the south and east of the site. In addition, populations of common amphibians such as California newt (Taricha torosa), which could be present on the site, are protected under CEQA. For these reasons, general amphibian and 6 Bulger, J. B. 1999. Terrestrial activity and conservation of California red-legged frogs (Rana aurora draytonii) in forested habitats of Santa Cruz County, California. Prepared for Land Trust of Santa Cruz County.

ITEM NO. 1.

Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

reptile preconstruction surveys of the entire site should be conducted by a Qualified Biologist(s) prior to any construction/ground disturbance on the site.
4) Bats
Mitigation Measure 3.3.6a in the biological report states that “A habitat assessment should be conducted to identify trees which support potentially suitable roosting habitat for bats. This can be conducted at any time of year and we recommend it is completed well in advance of the construction start date.” This mitigation measure is vague, and should specify how far in advance the bat habitat assessment survey should be completed. Furthermore, the project site has over 670 trees, including a high number of oak and sycamore trees on the property which are preferred trees for roosting bats due to the high frequency of suitable cavities for bats. In addition, the pallid bat (Antrozous pallidus) a California species of special concern, among others, is thought to be associated with oak woodlands (Pierson and Rainey, 2007) 7, and has been documented to occur approximately 2.5 miles east of the site (CNDDB, 2025).

Recommendation for Bats
The habitat assessment of the project site for bats should be conducted as part of the CEQA review of the project, rather than included as a preconstruction survey prior to development, due to the high potential for roosting bats on site. The habitat assessment survey should be conducted by a Qualified Biologist(s), and based on these findings, follow up emergence (nighttime) surveys during the bat maternity season (March 1 to October 15) may be necessary. If it is determined that a bat roost is present, CDFW should be consulted and a bat exclusion and mitigation plan should be prepared that is reviewed and approved by CDFW prior to implementation.
5) San Francisco Dusky-Footed Woodrat
The San Francisco dusky-footed woodrat (Neotoma fuscipes annectens) is a California species of special concern. Middens (nests) of this species were documented within the oak woodlands of the project site, and the property provides suitable habitat for this species. Mitigation Measure 3.3.7b in the biological report provides measures to minimize impacts to San Francisco dusky-footed woodrats, however the location of the middens was not provided in the biological report, and the site may provide habitat for several middens. Development of the site could impact the woodrat population in the area, and therefore more detailed information on the number of middens and their location is warranted.

Recommendation for San Francisco Dusky-Footed Woodrat
Due to the presence (and potential abundance of San Francisco dusky-footed woodrats on the project site) it is recommended that a more detailed survey and mapping of active woodrat middens should be conducted and a woodrat relocation plan should be prepared by a Qualified Biologist(s) and reviewed and approved by CDFW prior to implementation.

7 Bat Distribution in the Forested Region Of Northwestern California. Prepared By Elizabeth D. Pierson, California Department of Fish and Game and William E. Rainey, Ph.D. Wildlife Management Division Contract #FG-5123-WM November 2007. https://www.nrm.dfg.ca.gov/FileHandler.ashx?DocumentID=3835

ITEM NO. 1.

Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

6) Bumblebees/ Invertebrates)
Two special status bumble bee species are evaluated in the biological report: western bumble bee, (Bombus occidentalis); and Crotch’s bumble bee, (Bombus crotchii). They are shown in Table 2B: Special Status Species that Could Occur In the Project Vicinity and were determined to be absent from the project site. However habitat types present on the project site (grassland) are utilized by both of these species.

Additional special status invertebrates that were not included in Table 2B, that have some potential for presence include obscure bumblebee (Bombus caliginosus), and large marble butterfly (Euchloe ausonides).

The USFWS is currently reviewing a petition from the Xerces Society for Invertebrate Conservation, requesting that the large marble butterfly (Euchloe ausonides) be listed as a Threatened species and the large marble type subspecies (Euchloe ausonides ausonides) be listed as an Endangered species under the Act.8 Habitat for the large marble butterfly includes grasslands and open meadows along with streamsides, berms, beaches, canyons, montane slopes, and weedy flats. Feeds on plants of the mustard family.

The obscure bumble bee (Bombus caliginosus) is known to inhabit the grasslands and has been reported to nest underground in rodent burrows, in structures, or in decaying wood. This species is also difficult to distinguish from the more common yellow-faced bumblebee (Bombus vosnesenskii) and may be undocumented where present9.

Recommendation for Bumble bees / Invertebrates
Prior to any construction/ground disturbance on the site, a bumble bee survey and large marble habitat assessment should be conducted by a Qualified Biologist(s). Background information research should include citizen scientist data iNaturalist and Bumble Bee Watch as well as the CNDDB. If these species are detected on site, appropriate mitigation measures should be determined based on consultation with the US Fish and Wildlife Service.
7) Wildlife Movement Corridors
The biological report concludes that there would be no impact to wildlife corridors, however it does not include information on whether fencing (a potential wildlife movement barrier) will be installed or will be restricted from use on the site. In section 3.3.9 Impacts to Wildlife Movement Corridors, the report concludes that “Local urban species currently traversing the site for regular and dispersal movements would still be expected to cross the site post-build-out’.. and...”post build-out impacts to movement corridors for local wildlife are less-than significant.” 8 Department of the Interior Fish and Wildlife Service ,50 CFR Part 17 [FXES1111090FEDR–256–FF09E21000] Endangered and Threatened Wildlife and Plants; 90-Day Findings for Eight Species. January 21, 2025. https://www.govinfo.gov/link/fr/90/7038
9 A Petition to the State of California Fish and Game Commission to List Four Bumble Bees as Endangered under the California Endangered Species Act, Xerces Society, October 16, 2018. https://www.xerces.org/publications/policy-position-statements/petition-to-state-of-california-fish-and-gamecommission-tohttps://www.xerces.org/publications/policy-position-statements/petition-to-state-of-california-fishand-game-commission-to

ITEM NO. 1.

Results of Peer Review of Biological Evaluation Report and Related Documents for the 178 Twin Oaks Drive Project, Los Gatos, Santa Clara County, California – December 8, 2025

Recommendation for Wildlife Movement Corridors
The biological report should be amended, or a stand-alone document provided, that describes the measures that would be implemented to prevent impacts to movement of local urban wildlife species currently traversing the site.
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If you have any questions or require further information, please contact me.

Sincerely,
Patrick Kobernus
Principal Biologist

CRE LLC

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EXHIBIT C
Travel Times to Nearest Fire Station and Hospital

ITEM NO. 1.

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Home > Critical Care > Longer Emergency Care Travel Times Increase Presentation Complexity, Resource Use Longer Emergency Care Travel Times
Increase Presentation Complexity, Resource
Use
By For Physician's Weekly - Last Updated: May 8, 2025
Longer travel times for emergency surgical care increase case presentation complexity and healthcare system resource utilization, according to a recent study.

Longer patient travel times for emergency surgical care correlate with more complex presentations and increased operative interventions, transfers, admissions, extended stays, and costs, according to a study published online in JAMA Network Open.

According to the authors, timely access to emergency care is a critical performance metric for health systems, particularly for conditions in which delays exacerbate morbidity and mortality, MENU
8/5/26, 5:27 PM Longer Emergency Care Travel Times Increase Presentation Complexity, Resource Use | www.PhysiciansWeekly.com https://www.physiciansweekly.com/post/longer-emergency-care-travel-times-increase-presentation-complexity-resource-use 1/6

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such as surgical emergencies. Yet the relationship between travel time to an emergency facility and disease severity at presentation remained inadequately characterized. “Importantly, we evaluated travel time from patients’ homes to the facilities where they received emergency care—regardless of whether those facilities were able to provide definitive surgical care,” wrote corresponding author John W. Scott, MD, MPH, of the University of Washington, and study coauthors. “Therefore, we highlighted the potential benefit of preserving timely access to emergency departments that can provide initial care and stabilization of surgical patients, even if these facilities lack definitive surgical capabilities.” Retrospective Analysis
To examine whether prolonged travel time correlates with more complex disease on arrival, downstream clinical outcomes, and health system resource use, the researchers conducted a retrospective cohort analysis using statewide inpatient and emergency department administrative databases from Florida and California, encompassing nearly all adult encounters in 2021. The study included patients presenting with one of five common emergency general surgery conditions—appendicitis, cholecystitis, diverticulitis, hernia, or bowel obstruction. Travel time from the patient’s residence to the initial treating facility was the primary exposure, categorized as 15 minutes or less, 16–60 minutes, 61–120 minutes, and more than 120 minutes. The principal outcome was surgical disease complexity at presentation, defined by standardized severity criteria. Secondary outcomes comprised inpatient complications, inhospital mortality, operative intervention, length of stay, interfacility transfer, and total hospital charges. Multivariable logistic and linear regression models adjusted for demographics, comorbidities, insurance status, and hospital characteristics, reporting adjusted odds ratio (aOR) or mean differences with 95% confidence intervals (CI).

Impact of Travel Time
Of 190,311 adults with emergency surgical conditions, 7,138 (3.8%) resided more than 60 minutes from their treating facility. Compared to those within 15 minutes, patients traveling over 120 minutes exhibited significantly higher odds of presenting with complex disease (aOR 1.28; 95% CI 1.17–1.40). Extended travel time (≥ 60 minutes) was also independently associated with increased likelihood of operative intervention (aOR 1.17; 95% CI 1.10–1.26), inpatient admission (aOR 1.41; 95% CI 1.33–1.50), and interfacility transfer (aOR 1.32; 95% CI 1.15–

1.51). Furthermore, these patients experienced a longer adjusted inpatient stay by 0.47 days (95% CI 0.35–0.59) and incurred higher hospital charges by $8,284 (95% CI 5,532–11,035). “Prolonged travel time was not only associated with poor patient-level access to care, but with increased health system resource utilization as well,” the researchers wrote. “Patients with 8/5/26, 5:27 PM Longer Emergency Care Travel Times Increase Presentation Complexity, Resource Use | www.PhysiciansWeekly.com https://www.physiciansweekly.com/post/longer-emergency-care-travel-times-increase-presentation-complexity-resource-use 2/6

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Sodium Bicarbonate Fails to Boost InHospital Cardiac Arrest Outcomes Camille Prairie
Cardiology | August 3, 2026
“When … mortality is high, we are often reaching for
any possible therapy that may improve survival.”
Deepak Talr
Comparing Plasma & Whole-Blood
ddPCR for Pathogen Detection in
Suspected Sepsis
Maria Asimopoulos
Infectious Disease | July 30, 2026
Researchers compared plasma and whole-blood
droplet digital polymerase chain reaction testing in
cases of suspected sepsis.
longer travel times were more likely to require an operation, be admitted as inpatients, undergo interfacility transfer, have longer lengths of stay, and incur higher charges.” Travel Time as a Guide to Policy Decisions
The study authors suggested that travel time, as a dynamic indicator of access, may prove more actionable than static designations such as rurality when guiding policy decisions, adding, “These findings suggest that policymakers should account for proximity to emergency care when considering impacts of rural hospital closures and policy efforts to preserve timely access to care.”
References
Clark NM, et al. JAMA Netw Open.
2025;8(1):e2455258.doi:10.1001/jamanetworkopen.2024.55258 Related Posts

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As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.

Learn more: PMC Disclaimer | PMC Copyright Notice
Emerg Med J. 2007 Sep;24(9):665–668. doi: 10.1136/emj.2007.047654 The relationship between distance to hospital and patient mortality in emergencies: an observational study
Jon Nicholl
1 , James West
1 , Steve Goodacre
1 , Janette Turner
1 Author information Article notes Copyright and License information PMCID: PMC2464671 PMID: 17711952
Abstract
Objectives
Reconfiguration of emergency services could lead to patients with life‐threatening conditions travelling longer distances to hospital. Concerns have been raised that this could increase the risk of death. We aimed to determine whether distance to hospital was associated with mortality in patients with life‐threatening emergencies.

Methods
We undertook an observational cohort study of 10 315 cases transported with a potentially life‐ threatening condition (excluding cardiac arrests) by four English ambulance services to associated acute hospitals, to determine whether distance to hospital was associated with mortality, after adjustment for age, sex, clinical category and illness severity. 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 1/12

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Results
Straight‐line ambulance journey distances ranged from 0 to 58 km with a median of 5 km, and 644 patients died (6.2%). Increased distance was associated with increased risk of death (odds ratio

1.02 per kilometre; 95% CI 1.01 to 1.03; p<0.001). This association was not changed by adjustment for confounding by age, sex, clinical category or illness severity. Patients with respiratory emergencies showed the greatest association between distance and mortality.

Conclusion
Increased journey distance to hospital appears to be associated with increased risk of mortality.

Our data suggest that a 10‐km increase in straight‐line distance is associated with around a 1% absolute increase in mortality.

Keywords: emergency services, health service research, mortality It has recently been suggested that reconfiguration of emergency care to concentrate services in a limited number of specialist centres could save thousands of lives each year in the UK, and that opposing the closure of local services could counterintuitively cost lives. 1 In opposition to this
view, concerns have been raised that reconfiguration could lead to acutely ill patients having to be transported greater distances to hospital with an associated risk of increased mortality. Few published studies have addressed this issue, so there is a risk that policy‐making may be driven by anecdote or supposition.

We have recently completed a study to assess the effect on mortality among patients with life‐ threatening emergencies of implementing response time standards in four ambulance services. 2 We have used these data to determine whether longer journey distances to hospital were associated with an increased risk of mortality.

Methods
Call identification
8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 2/12

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Ambulance services use emergency medical dispatch (EMD) systems to prioritise 999 calls. Two systems were used during this study: the Advanced Medical Priority Dispatch System (AMPDS) and the Criteria Based Dispatch (CBD) system. Each provides structured protocols that allow trained emergency medical dispatchers to categorise 999 calls depending on urgency, and assigns each call a priority code based on condition and urgency. The Department of Health (DH) has identified a set of EMD codes for each system that correspond to conditions that are potentially life‐threatening and to which the highest priority (category A) ambulance response should be made. We selected for inclusion in the study a subgroup of category A calls identified using the DH codes, in which the patient was reported as unconscious or not breathing or with acute chest pain.

We termed these A* calls. Exclusion criteria were A* calls where patients were found dead at the scene, or were discharged at the scene and not conveyed to hospital, or were treated in hospitals other than those in our study areas; calls where no vehicle attended the scene; and out‐of‐hospital cardiac arrests (the last category was excluded because survival from out‐of‐hospital cardiac arrest has clearly been shown to depend upon the time from call to treatment that can be provided by ambulance staff, rather than time or distance from scene to hospital). 3 Data collection
Consecutive, life‐threatening category A ambulance calls were sampled annually from 1997 to 2001 from four ambulance services: the Royal Berkshire, Derbyshire, Essex and West Midlands.

These services were representative of the types of environment typically encountered in England and included urban, mixed urban and rural, and very rural areas. In 1999, the Derbyshire, Nottinghamshire and Leicestershire ambulance services merged to become East Midlands Ambulance Service NHS Trust. Two services used CBD, one used AMPDS, and one used CBD at the beginning of the study and changed to AMPDS halfway through.

From all category A calls, we sampled approximately 1000 consecutive A* calls from each service in each year, using the same sampling period for each service for all years. The ambulance service dispatch system provided patient information (name, sex, age), grid reference for the incident, and dispatch category codes. This information was then used to identify the paper ambulance patient report forms (PRFs). From the PRFs, further information was obtained about the patient (name, date of birth and address), incident description, the patient condition on arrival of the crew (including vital signs), details of treatment given, disposal of the patient (left at the scene or transported to hospital) and outcome at this point (alive or deceased).

From the grid references of the incident and hospital, we calculated the straight‐line ambulance journey distance from scene to hospital. These straight‐line distances were preferred to journey 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 3/12

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times to hospital because journey times depend on the accuracy and consistency with which times of leaving the scene and arrival at hospital are recorded, and they can also be affected by ”reverse causation”. This occurs when the patient condition is a cause of the journey time rather than vice versa, such as when ambulances drive as fast as possible to hospital for critically ill patients but more slowly and with less risk for patients not critically ill.

If the patient was taken to hospital, the emergency department (ED) notes were identified and information recorded on time of arrival and discharge from the ED, patient condition including vital signs, cardiac rhythm (for cardiac patients), preliminary diagnosis, condition on leaving the ED and disposal. If admitted, details of the length of stay, final diagnosis and disposition were recorded. For any patient who died, details were recorded of the date, time, place and cause of death. If the patient died before reaching hospital and was taken directly to the mortuary, the cause of death was obtained by accessing death certificates from the coroner or the National Health Service (NHS) Central Registry.

Details of patients taken to hospital, for whom no records could be found, were also sent to the NHS Central Registry. For those identified as dead, the date, place and cause of death were obtained and used to identify those who had died as a result of the incident for which the call was made and those who had survived.

Ethics approval was obtained, covering 27 hospitals that patients could be taken to within the geographical boundary of each of the ambulance services.

Analysis
We planned to test for an association between journey distance to hospital and mortality. Such an association could be confounded by illness severity. Patients living further from hospital may have a higher threshold for calling for help and may therefore be more ill and at higher risk of death.

There is currently no widely validated system for risk‐adjusting emergency medical cases, but the Rapid Emergency Medicine Score (REMS) has been validated in a local setting 4 and shown to
predict mortality in our cohort.
5 This score uses six variables (age, Glasgow Coma Score (GCS), oxygen saturation, pulse, blood pressure and respiratory rate) to give each patient a score between 0 (lowest predicted mortality) and 20 (highest). We therefore planned to examine whether patients with a longer journey distance had higher REMS scores and determine whether any association between distance and mortality was confounded by illness severity by testing the association in a multivariate analysis, with REMS score included as a covariate. Because full REMS scores were only available for a small number of patients, we also tried adjusting for partial scores based only 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 4/12

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on age and GCS, which were available for 80.8% of patients. We also tried adjusting for sex, categorical age, and clinical category coded as chest pain (any cause), respiratory disease or symptoms, and injury, poisoning, asphyxiation or haemorrhage, or other and unknown. By including ”other and unknown” as a category all cases were included in this analysis. All analyses were undertaken using SPSS V.11.0 (SPSS Inc, Chicago, Illinois, USA).

Results
Numbers
During the 5‐year period, A* calls resulted in ambulance attendance for 11 794 patients who met the study inclusion criteria and who were followed up to discharge or traced through the NHS Central Register. Of these, we excluded 1479 from this analysis because distance to hospital could not be calculated. This resulted in a study sample of 10 315 (58.3% male, with a median age of 61 years).

Analyses
Ambulance journey distances ranged from 0 to 58 km, with a median of 5 km. Overall, 644 patients died (6.2%). Table 1 shows how mortality varied with straight‐line distances, categorised as short (<10 km), medium (10–20 km) or long (>20 km). Longer distances were associated with higher mortality (p<0.002, χ
2 test for trend). Logistic regression showed that mortality increased with each additional kilometre of distance travelled, with an odds ratio (OR) of 1.02 per kilometre (95% CI 1.01 to 1.03; p<0.001). Some association was observed in all four clinical categories, but it was particularly striking for patients with respiratory problems (fig 1). 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 5/12

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Table 1 Relationship between ambulance journey distance and survival to discharge.

Distance category (km)
Outcome
Survived (%) Died (%) Total
0–10 7725 (94.2) 475 (5.8) 8200
11–20 1479 (92.3) 124 (7.7) 1603
21+ 467 (91.2) 45 (8.8) 512
Total 9671 (93.8) 644 (6.2) 10315
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Figure 1 Variation in mortality with distance to hospital, by clinical category.

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🔍
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A full REMS score could be calculated for 3882 patients (37.6%). The mean REMS score was 6.79 (95% CI 6.67 to 6.91) for those with a short journey distance, 7.22 (6.92 to 7.51) for those with a medium journey distance and 7.33 (6.78 to 7.88) for those with a long journey distance. The association between journey distance and mortality remained significant after inclusion of REMS score in the logistic regression to adjust for potential confounding by disease severity (OR=1.03; 95% CI 1.01 to 1.05; p=0.006).

Missing oxygen saturation information was the main reason why a full REMS score could not be calculated, so we repeated the analysis using only the age and GCS components of REMS. We have previously shown that age, GCS and oxygen saturation are the only components of the REMS score that are independent predictors of mortality in our cohort. 5 We were able to include 8335 (80.8%)
cases and found that the association between journey distance and mortality remained significant (OR=1.018; 95% CI 1.005 to 1.03; p=0.005).

Adjusting for age, sex, and clinical category, and including all 10 315 patients in the analysis, strengthened the evidence for the observed association (OR=1.02; 95% CI 1.01 to 1.03; p<0.001).

Discussion
Increased journey distance to hospital seems to be associated with increased risk of mortality, even after potential confounding by illness severity is taken into account. Our data suggest that each additional kilometre is associated with a 2% relative increase in mortality. This equates to an approximate 1% absolute increase in mortality associated with each 10‐km increase in straight‐ line distance. Our results show a sharp increase in mortality in patients with respiratory problems, but less change in patients with chest pain. This is clinically plausible. This means that, other things being equal, closing local EDs could result in an increase in mortality for a small number of patients with life‐threatening emergencies, who have to travel further as a result.

Other evidence
Our results concur with a number of studies from around the world that have shown increased mortality in rural compared with urban trauma. However, much of this can be explained by the increased severity of road traffic crashes and increased ambulance response times in rural areas.

Furthermore, results may not be generalisable from trauma to other emergency medical conditions nor from one emergency system to another. Only a few studies have examined hospital accessibility and outcomes in the UK. Studies of road traffic crashes in Norfolk, 6 all serious trauma
8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 7/12

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in Scotland,
7 and ruptured abdominal aortic aneurysms in West Sussex8 all failed to find any relationship between time to hospital and mortality. However, in line with our findings, two studies of the relationship between accessibility and mortality in asthma patients have found a 10% increase in the relative risk of death for each 10‐km increase in distance, 9 and a 7% increase
for each 10‐minute increase in journey time.
10 Limitations
A number of potential limitations of our study should be considered when interpreting these results. First, this is an observational study, and inferring causality from our observed associations is fraught with difficulties, most notably by confounding. Although we attempted to adjust for confounding by illness severity and case mix, it is possible that at least some of the observed association may be explained by residual confounding. Second, we deliberately selected ambulance service calls that suggested patients might have life‐threatening conditions and a high risk of mortality. Our findings should not be applied to the vast majority of patients transported to hospital by ambulance, who have a much lower risk of death. Third, our results reflect associations between distance and outcome within the emergency care system as it performed between 1997 and 2001. Changes in performance in recent years or new policies that have changed to both increase distances and either improve care at the more distant facilities or improve the effectiveness of prehospital care could attenuate the potential effect of increased journey distance upon mortality.

The emergency medical system and future research
There is good evidence for some groups of emergency patients that care provided in specialist centres improves outcomes.
1 Examples include primary angioplasty for acute myocardial infarction,
11 and care for major trauma patients with multiple injuries.12 In these cases we can be
reasonably confident that with appropriate pre‐hospital care and at distances typical in the UK, the benefits of specialist care, which is only available in certain centres, would outweigh any detriments resulting from the increased travel distances to the centres. However, there are also some groups of critically ill patients who need urgent but not specialist care. For example, patients in anaphylactic shock, choking, drowning, or having acute asthma attacks need urgent care that would be the same wherever it is provided. For these patients, there may be a detriment in having to travel increased distances. Of course, if care for these types of patients, although the same wherever it is provided, were to be of higher quality in high‐volume centres, there might be other arguments for concentrating emergency care in some centres by closing local EDs. However, 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 8/12

ITEM NO. 1.
although the evidence for improved outcomes at higher volumes is reasonably robust for a few conditions,
13 it is almost non‐existent for ED care.
14 The debate between local emergency care and more distant, high‐volume or specialist centre care has also confused the issue of hospital bypass with the issue of ED closure. The evidence that some critically ill patients have the capacity to benefit from specialist care is an argument for bypass, not an argument for closure or restriction of hours of non‐specialist centres. Patients with specialist needs such as burns and serious head trauma are already taken directly or indirectly to specialist centres. The current debate should be about extending the list of patient conditions that should bypass local hospitals and be taken to specialist centres, rather than about the closure of locally accessible 24‐hour EDs. Closure enforces bypass for those patients who would benefit but at a cost for any patients who will not benefit.

Nevertheless, the optimum configuration of local and specialist emergency care centres for an effective and efficient emergency care system is unclear. Research is needed to investigate the benefits of different system configurations rather than the effectiveness of different services. One potentially fruitful avenue for future research aimed at resolving these issues would be to model the emergency medical system, populating the model based on the epidemiology of emergencies in the UK, and using the available evidence on risks and benefits by distance or time and setting.

Conclusion
Decisions regarding reconfiguration of acute services are complex, and require consideration of many conflicting factors. Our data suggest that any changes that increase journey distances to hospital for all emergency patients may lead to an increase in mortality for a small number of patients with life‐threatening medical emergencies, unless care is improved as a result of the reorganisation. However, even then it is not certain that it would be acceptable to trade an increased risk for some groups of patients, such as those with severe respiratory compromise, for a reduced risk in other groups such as those with myocardial infarction.

Abbreviations
AMPDS - Advanced Medical Priority Dispatch System
CBD - Criteria Based Dispatch
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DH - Department of Health
ED - emergency department
EMD - emergency medical dispatch
GCS - Glasgow Coma Score
NHS - National Health Service
PRF - patient report form
REMS - Rapid Emergency Medicine Score
Footnotes
Funding: The original ambulance response times study was undertaken by the Medical Care Research Unit, which is core funded by the UK Department of Health. The views expressed here are those of the authors and not necessarily those of the Department.

Competing interests: None.

References

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London: Institute for Public Policy Research, 2007,
http://www.ippr.org.uk/members/download.asp?f=
%2Fecomm%2Ffiles%2Ffuture%5Fhospital%2Epdf Accessed 13 July 2007

2. Turner J, O'Keefe C, Dixon S.et alThe costs and benefits of changing ambulance service response time standards. Sheffield: Medical Care Research Unit, University of Sheffield, 2005

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Articles from Emergency Medicine Journal : EMJ are provided here courtesy of BMJ Publishing Group 8/5/26, 5:10 PM The relationship between distance to hospital and patient mortality in emergencies: an observational study - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC2464671/ 12/12

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As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.

Learn more: PMC Disclaimer | PMC Copyright Notice
JAMA Surg. 2017 Jul 19;152(10):983–984. doi: 10.1001/jamasurg.2017.2230 Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas
Howard K Mell
1,✉, Shannon N Mumma2
, Brian Hiestand
2 , Brendan G Carr
3 , Tara Holland
4 , Jason Stopyra
2 Author information Article notes Copyright and License information PMCID: PMC5831456 PMID: 28724118
See commentary "Converting Bystanders to Immediate Responders: We Need to Start in High School or Before." with doi: 10.1001/jamasurg.2017.2231.

Abstract
This study describes the interval between receipt of a 911 call and the arrival of the first emergency medical service unit on the scene of a reported emergency in the United States.

Emergency medical service (EMS) personnel in the United States respond to an estimated 37 million 911 calls annually, providing care to the sick and injured, but the initial link in the chain of survival includes family, friends, and bystanders. A collaborative effort between emergency care and emergency management experts within the US government recently led to the development of a public education campaign titled Until Help Arrives (https://community.fema.gov/until-helparrives ). Spearheaded by the US Departments of Homeland Security, Defense, and Health & 8/5/26, 4:29 PM Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5831456/ 1/5

ITEM NO. 1.

Human Services, this initiative seeks to empower laypersons to provide care to the ill and injured until EMS personnel arrive. While there is an unavoidable delay between a 911 call and EMS arrival, to our knowledge, no current published data exist to quantify these time frames. This study seeks to describe the interval between receipt of a 911 call and the arrival of the first EMS unit on the scene of a reported emergency in the United States.

Methods
We reviewed deidentified EMS records from calendar year 2015 from 485 EMS agencies distributed throughout the United States (ESO Solutions). Encounters were distributed geographically throughout the country and were classified, based on the 2014 US Census Bureau categorization of the originating zip code, as rural (population <2500), urban (urbanized centers, population >50 000), or suburban (urban clusters, population 2500-50 000).

Only emergency (911) prehospital encounters were included. We excluded patient transfers, encounters coded as aborted encounter, and all encounters with arrival times 120 minutes or longer or transport times 180 minutes or longer (as these outliers were not representative of the general EMS experience). One author (B.H.) examined the data for obvious errors and outliers, and corrected data errors resulting from the use of a 12-hour am/pm clock. All other data entry errors resulted in the calculated time interval being set to missing. Given the lack of other covariates available for incorporation, multiple imputation was not valid for dealing with missing data.

Therefore, complete case analysis was used to generate descriptive statistics. The study was determined to be exempt from review by the institutional review board at the Wake Forest Baptist Medical Center.

Results
Data were provided for 1 796 987 EMS encounters. There were 625 encounters identified as outliers and excluded as described here. Table 1 provides the distribution of encounter types in the database. A total of 71% of encounters (n = 1 275 529) resulted in transport of a patient by the primary EMS unit. There were 70 189 encounters (3.9%) from rural zip codes, 1 576 019 (87.7%) from suburban zip codes, and 150 779 (8.4%) from urban zip codes. Table 2 provides time data for the various encounter types by population category.
8/5/26, 4:29 PM Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5831456/ 2/5

ITEM NO. 1.

Table 1. Distribution of Emergency Medical Services Encounters by Category.

Category No. (%)
Aborted encounter 6116 (0.34)
Dead on arrival 20 771 (1.2)
No patient found on scene 39 397 (2.2)
Patient encounter without transport by primary unit 455 174 (25.3) Patient encounter with transport by primary unit 1 275 529 (71) Total 1 796 987 (100)
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Table 2. Response Time Data for Emergency Medical Services Encounters by Zip Code Classification.

Category No. Median (IQR),
min
Arrival Time, min
90th Percentile Mean (SD)
Suburban 1 538
203
6 (4-10) 14 7.7 (5.4)
Urban 146 682 6 (4-9) 12 7.0 (4.4)
Rural 68 283 13 (8-19) 26 14.5 (9.5)
Overall 1 753
168
7 (4-10) 14 7.9 (5.7)
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Abbreviation: IQR, interquartile range.
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Discussion
Emergency medical service units average 7 minutes from the time of a 911 call to arrival on scene.

That median time increases to more than 14 minutes in rural settings, with nearly 1 of 10 encounters waiting almost a half hour for the arrival of EMS personnel. Longer EMS response times have been associated with worse outcomes in trauma patients. In some, albeit rare, emergent conditions (eg, cardiopulmonary arrest, severe bleeding, and airway occlusion), even modest delays can be life threatening. Our data are limited in that most encounters derive from urban cluster zip codes and are derived from a convenience sample as opposed to a selected series of representative census tracts. However, the large sample size provides external validity to our findings.

Research suggests that bystanders trained in first aid can and will effectively assist the ill and injured in their time of need. Our data suggest that there is an interval for bystander intervention between 911 system engagement and EMS arrival. Recognizing that “you are the help until help arrives” may be lifesaving.

References

1. Federal Interagency Committee on Emergency Medical Services 2011 National EMS Assessment: DOT HS 811 723. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2012. [Google Scholar ]

2. Ratcliffe M, Burd C, Holder H, Fields A. Defining Rural at the US Census Bureau ACSGEO-1.

Washington, DC: US Census Bureau; 2016. [Google Scholar ]

3. Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB. Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? a statewide analysis. Am J Surg. 2009;197(1):30-34. [DOI ] [PubMed] [Google Scholar ]

4. Ashour A, Cameron P, Bernard S, Fitzgerald M, Smith K, Walker T. Could bystander firstaid prevent trauma deaths at the scene of injury? Emerg Med Australas. 2007;19(2):163- 168. [DOI ] [PubMed] [Google Scholar ]

5. Arbon P, Hayes J, Woodman R. First aid and harm minimization for victims of road trauma: a population study. Prehosp Disaster Med. 2011;26(4):276-282. [DOI ] [PubMed] [Google Scholar ]
8/5/26, 4:29 PM Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5831456/ 4/5

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6. Bakke HK, Steinvik T, Eidissen SI, Gilbert M, Wisborg T. Bystander first aid in trauma:
prevalence and quality: a prospective observational study. Acta Anaesthesiol Scand. 2015;59(9):1187-1193. [DOI ] [PMC free article] [PubMed] [Google Scholar ] Articles from JAMA Surgery are provided here courtesy of American Medical Association 8/5/26, 4:29 PM Emergency Medical Services Response Times in Rural, Suburban, and Urban Areas - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5831456/ 5/5

ITEM NO. 1.

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The Silent Delay: How
Traffic Congestion Kills
Emergency Patient
By Medarr Health December 14, 2025 6 min read
By the time an ambulance turns on its siren, the emergency has already begun. Somewhere inside that vehicle, a life is balancing on minutes. A child struggling to breathe. A woman hemorrhaging after childbirth. A man clutching his chest as his heart starves for oxygen. The siren is not a request. It is a warning that time has become dangerous.

Yet across many African cities, especially in Nigeria, that warning is swallowed by traffic.

Cars remain bumper to bumper. Drivers hesitate, unsure where to move. Some refuse to give way. Others are boxed in by narrow roads and poor planning. Hawkers weave between
lanes. Motorcycles cut across paths. The ambulance crawls forward, meter by meter, while inside, a patient slips closer to a point no doctor can reverse.

This is the silent delay. It does not make headlines. It leaves no visible wreckage on the road. But it kills, every day.

When Time Is the Treatment
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ITEM NO. 1.

In emergency medicine, time is not a convenience. It is often the treatment itself.

There is a concept doctors live by called the “golden hour.” For trauma, strokes, cardiac arrest, severe bleeding, and respiratory failure, outcomes are dramatically better when care begins within the first hour. In many cases, it is not the sophistication of treatment that saves the patient, but how fast it starts.

A stroke patient who reaches care early may walk again. One who arrives late may never speak.

A bleeding mother treated promptly survives. Delayed, she becomes a statistic.

A crash victim stabilized quickly lives. Stuck in traffic, they bleed out silently.

Traffic congestion steals this time invisibly. It turns survivable emergencies into fatal ones, not through violence, but through delay.

The Ambulance Myth We Tell Ourselves
There is a dangerous myth many of us unconsciously believe:
that ambulances arrive too late because systems are weak, hospitals are far, or emergencies are unavoidable. Traffic, we assume, is just unfortunate background noise.

But evidence and experience tell a different story.

In many urban areas, the distance between a patient and a capable hospital is not extreme. What stretches a ten-minute Blogs Medarr System How it works
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ITEM NO. 1.
drive into forty minutes is congestion, poor road design, lack of right-of-way enforcement, and public indifference.

Ambulances are delayed not only by traffic volume, but by behavior. Drivers who refuse to yield. Vehicles parked
indiscriminately. Roads without shoulders. Junctions without control. Sirens treated as irritations rather than alarms.

The result is a deadly contradiction: emergency vehicles exist, trained personnel exist, hospitals exist, but patients still die because the road becomes an obstacle.

Inside the Ambulance: A Perspective We
Rarely Consider
We often see ambulances from the outside. Flashing lights. Loud sirens. Impatience.

We rarely imagine what is happening inside.

A paramedic counting compressions during CPR.

An oxygen cylinder running low.

A child’s pulse fading.

A clinician making decisions with incomplete information, knowing that every delay worsens the odds.

Ambulance crews describe the frustration vividly. They know what must be done, they know where they need to go, and they know the patient might survive if they arrive in time. But they are trapped by traffic that does not recognize urgency.

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ITEM NO. 1.

For healthcare workers, these delays are not abstract. They carry the weight of “almosts.” Almost made it. Almost saved them. Almost arrived on time.

That burden accumulates. It leads to burnout, moral injury, and a quiet despair that no amount of training can fix if the system itself works against speed.

Why Traffic Congestion Is Especially
Deadly in Africa
Traffic congestion kills emergency patients everywhere, but its impact is magnified in African cities for several reasons.

First, ambulance density is low. There are fewer emergency vehicles per population compared to high-income countries.

This means each ambulance delay affects more people.

Second, pre-hospital care systems are underdeveloped. In many cases, ambulances are not dispatched through a
coordinated emergency number. Families, bystanders, or
drivers arrange transport themselves. When traffic blocks the road, there is often no alternative route or support.

Third, hospitals are not evenly distributed or coordinated.

Patients are sometimes taken to the nearest hospital, only to be referred elsewhere due to lack of capacity. Traffic delays compound these transfers, turning a chain of referrals into a deadly marathon.

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ITEM NO. 1.

Fourth, urban planning has not prioritized emergency corridors.

Roads are narrow. Shoulders are nonexistent. Markets spill onto highways. Traffic enforcement is inconsistent. Ambulances have no guaranteed path.

Finally, public awareness is low. Many drivers genuinely do not know what to do when an ambulance approaches. Others
distrust sirens because of misuse by non-emergency vehicles.

This confusion costs lives.

The Chain Reaction of Delay
Traffic congestion does not act alone. It triggers a cascade of failures.

Delayed arrival means delayed diagnosis.

Delayed diagnosis means delayed treatment.

Delayed treatment increases complications.

Complications increase hospital strain.

Strain increases rejection and referral.

Referral sends patients back into traffic.

The system eats its own tail.

A patient stuck in traffic arrives unstable. The hospital struggles to manage them. The outcome worsens. Another patient now occupies scarce resources. The next ambulance faces even longer delays.

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ITEM NO. 1.
entire healthcare ecosystem.

The Cost We Do Not Measure
We count road traffic deaths. We count hospital mortality. But we rarely count deaths caused by delay.

There is no checkbox on a death certificate for “arrived too late due to traffic.” There is no national dashboard tracking minutes lost to congestion. Families bury loved ones without ever knowing that a clear road might have changed the story.

The economic cost is enormous. Survivors of delayed care often live with disabilities that reduce productivity. Families lose breadwinners. Hospitals spend more treating advanced
complications than they would have spent on early intervention.

The emotional cost is immeasurable. Guilt. Anger. Trauma. The haunting question: “What if we had arrived earlier?”
Giving Way Is Not Courtesy. It Is Care.

In many places, giving way to an ambulance is framed as politeness. In reality, it is medical participation.

When a driver moves aside, they are not just obeying traffic etiquette. They are extending oxygen to someone who cannot breathe. They are slowing blood loss. They are buying time for a brain that is dying cell by cell.

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ITEM NO. 1.

Emergency response is not confined to hospitals. It begins on the road, with ordinary people making small decisions that have enormous consequences.

One car pulling aside may seem insignificant. But multiplied across traffic, it becomes a corridor of survival.

Beyond Sirens: Why Clearing the Road Is
Not Enough
Even when ambulances break through traffic, another delay often waits at the hospital gate.

Rejection.

Lack of preparation.

No prior notice.

No available bed.

This is where traffic delay meets hospital delay, forming a deadly partnership.

Emergency response is a chain. Roads are one link. Hospitals are another. Information is the connector.

Without coordination, ambulances arrive unannounced.

Hospitals scramble. Patients wait. Outcomes worsen.

This is why solving traffic congestion alone is not enough. We must also solve what happens after the ambulance arrives.

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ITEM NO. 1.

The Role of Technology in Breaking the
Delay
Technology cannot widen roads overnight, but it can shrink uncertainty immediately.

When hospitals receive advance information about incoming emergencies, they prepare. When they signal availability, ambulances choose better destinations. When routing is
intelligent, time is saved even in traffic.

This is where platforms like Medarr become critical, not as abstract innovation, but as practical tools.

By allowing emergency details to be sent ahead, by enabling hospitals to respond digitally, by guiding routing based on readiness, technology reduces wasted movement. It shortens the time between crisis and care.

Traffic may still exist, but blind traffic becomes informed movement.

Ambulance Way: A Cultural Shift, Not a
Campaign
Clearing the road is not just about enforcement. It is about culture.

Ambulance Way is rooted in a simple idea: that every road user is part of the emergency response system. That saving lives is Blogs Medarr System How it works
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ITEM NO. 1.
not limited to doctors and nurses. That respect for sirens reflects respect for life.

When drivers anticipate ambulances, when cities design
corridors, when enforcement is consistent, when technology connects road to hospital, delays shrink.

Lives follow.

A Future That Is Still Possible
Imagine an emergency where traffic slows but parts
instinctively.

Where drivers know exactly where to move.

Where ambulances choose hospitals before departure.

Where hospitals prepare before arrival.

Where rejection becomes rare, not routine.

This future does not require perfection. It requires intention.

It requires recognizing that traffic congestion is not just an inconvenience, but a public health threat. That roads are not neutral spaces. They either help save lives or help end them.

The Question We Must Answer
Every time an ambulance is trapped in traffic, a quiet question hangs in the air:

Was this delay necessary?
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8/5/26, 4:26 PM The Silent Delay: How Traffic Congestion Kills Emergency Patient - Medarr Health Journal https://medarr.com/blog/the-silent-delay-how-traffic-congestion-kills-emergency-patient/ 10/15

ITEM NO. 1.

Categorized in: Ambulance Way, Emergency Care
Last Update: December 14, 2025
Tagged in: Ambulance
If the answer is no, then the death that follows is not fate. It is failure.

Failure of awareness.

Failure of coordination.

Failure of systems.

But failures can be corrected.

The silent delay can be made visible.

The invisible killer can be confronted.

The road can become part of the cure.

Because in emergencies, the difference between life and death is often not skill, not equipment, not even money.

It is time.

And time, once lost in traffic, never comes back.

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8/5/26, 4:26 PM The Silent Delay: How Traffic Congestion Kills Emergency Patient - Medarr Health Journal https://medarr.com/blog/the-silent-delay-how-traffic-congestion-kills-emergency-patient/ 11/15

ITEM NO. 1.

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The Deadly Equation: When Minutes Mean Mortality
November 21, 2025
Why Emergency Delays Kill: The Hidden Crisis in African Healthcare
November 21, 2025
Reimagining Emergency Response in Africa: How Bystanders, Hospitals, and Technology Can Save More Lives
November 21, 2025
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