Though the service has cut down the time people are waiting for ambulances to arrive, many still face long waits waiting to be handed over to hospital staff.
At a meeting of the service's board of directors on Wednesday the challenges facing staff and patients were discussed.
Anthony Marsh, the West Midlands Ambulance Service's (WMAS) chief executive officer, said: "Patient handover delays have improved, but hours lost to operational activity continue to result in significant patient harm and the impact of these delays resulting in long patient waiting times also causes harm, including death.
"As a result of long delays, the number of serious incidents involving serious harm or death remains significant. The risk rating therefore remains at a 25."
WMAS is getting 800 new ambulances, including 100 mental heath response vehicles, from NHS England to combat its problems.
However, chairman Professor Ian Cumming warned the next year would be "very tough".
He said: "This is going to be a very tough year, especially with the pressure from hospital handover delays and the financial challenges we face. However, I am confident we have the right team to get through it."
In a report to the board of directors the scale of the time due to handovers was laid bare.
The report said: "The issue of patient handover delays has shown some signs of improvement during January and February, but we are still losing significant hours compared to the position pre-Covid.
"The lost hours for the year plateaued across August and September, fell in November, but worsened again in December to give the worst month ever for lost hours due to patient handover delays, with over 48,000 rostered hours lost.
"Lost hours has an opportunity cost, i.e. the patients that could have had a quicker response and the lives that could have been saved; there is also a financial cost of the lost hours, which for December alone equated to £8.2m."