Concerns raised 1
Failure to maintain emergency department capacity and timely patient flow View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Geoffrey Gordon Fuller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain emergency department capacity and timely patient flow
Wider context from the report “1. On the day of Mr Fuller’s ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients . ED accommodated the surplus patients on trolleys in corridors, seated within the waiting room or remaining inside ambulances in the parking area outside ED.
2. The situation had not improved as at the date of this Inquest.
3. EDs have a national target for 95% of patients to be admitted, transferred or discharged within 4 hours. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed. This increased mortality is partly attributed to the fact that patients in ED are not receiving the surgery or specialist care that is available on the wards.
4. Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients. For the opening months of 2026 approximately 50% of patients have still been in ED after 4 hours .
5. RCHT witnesses reported that over the last few weeks the ED has been regularly required to accommodate over 100 patients (in a unit with a capacity for 42 patients) . This has involved significant numbers of patients still in ED after 12 hours, some still in ED after 24 hours .
” Source location Geoffrey Gordon Fuller · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest over £450 million to expand urgent and emergency care capacity through the 2025/26 delivery plan.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.
Verbatim wording from the response “We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Failure to provide a designated clinical area for emergency department patients when capacity is reached View source
Linked responses
Department of Health and Social Care NHS England University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 21
Department of Health and Social Care
Continue action to improve patient flow across the urgent and emergency care pathway.
View source
Department of Health and Social Care
Continue action to expand available urgent and emergency care capacity.
View source
Department of Health and Social Care
Provide focused support to the most challenged trusts.
View source
University Hospitals Sussex NHS Foundation Trust
Strengthen direct-to-specialty pathways and expand acceptance criteria for patients accepted directly by hospital specialties.
View source
University Hospitals Sussex NHS Foundation Trust
Direct inter-hospital referrals to inpatient beds rather than routing them through the Emergency Department.
View source
University Hospitals Sussex NHS Foundation Trust
Operate a 24/7 medical Same Day Emergency Care unit to stream suitable patients away from the Emergency Department.
View source
University Hospitals Sussex NHS Foundation Trust
Explore working with NEWTON to decompress the Emergency Department, strengthen Same Day Emergency Care, and improve flow for patients without a criteria to reside.
View source
University Hospitals Sussex NHS Foundation Trust
Run Emergency Physician In Charge and corridor huddles continuously to review corridor patients, identify pathways, and escalate risks.
View source
University Hospitals Sussex NHS Foundation Trust
Operate and regularly review the Hospital Alternative Oversight Programme and its admission-avoidance, flow, discharge, virtual-care, frailty, therapy, and urgent-care initiatives.
View source
University Hospitals Sussex NHS Foundation Trust
Collaborate with the local Mental Health Trust to secure timely mental health admission or avoid Emergency Department attendance.
View source
University Hospitals Sussex NHS Foundation Trust
Use ambulatory Emergency Department space effectively to maximise clinical capacity and reduce overcrowding.
View source
University Hospitals Sussex NHS Foundation Trust
Operate the Medicine Division’s Continuous Flow Model to move patients earlier from the Acute Floor and reduce Emergency Department admission waits.
View source
University Hospitals Sussex NHS Foundation Trust
Implement local corridor-care safety measures, including digital observations and prescribing, intentional rounding, corridor standards, high-risk reviews, and dedicated monitoring space.
View source
University Hospitals Sussex NHS Foundation Trust
Complete phase one of the Acute Floor Reconfiguration programme, including opening the new Acute Medical Unit and 24/7 Medical Same Day Emergency Care unit.
View source
NHS England
Publish the Urgent and Emergency Care Plan and Medium-Term Planning Framework setting national expectations to eliminate corridor care.
View source
NHS England
Support providers and Integrated Care Boards to improve hospital flow through faster senior decisions, same-day emergency care and virtual wards.
View source
NHS England
Support providers and Integrated Care Boards to reduce emergency-department demand through community and primary-care alternatives and strengthened admission-avoidance pathways.
View source
NHS England
Support providers and Integrated Care Boards to strengthen discharge processes through criteria-led discharge and discharge-to-assess models.
View source
NHS England
Develop Model Discharge guidance to reduce discharge delays and improve patient flow.
View source
NHS England
Provide targeted regional support to systems experiencing the highest levels of patient-flow pressure.
View source
NHS England
Publish corridor-care data routinely to increase transparency and enable focused intervention where patient-safety risks are greatest.
View source See 18 more actions
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AI-generated summary
David John Smart · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David John Smart developed a life-threatening rectal bleed after a polypectomy and required surgery after conservative management continued to be unsuccessful. He died from known complications of Andexanet Alfa, used to reverse Rivaroxaban so that surgery could be performed. The inquest raised concerns about patients being cared for in corridors when the Emergency Department reached capacity, including the continued use of corridors despite actions intended to improve patient flow.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide a designated clinical area for emergency department patients when capacity is reached
Wider context from the report “During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so . I understand from previous inquests that the area is not designated as a clinical area .
I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.
The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity .
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country .
Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in December 2022 and February 2025 and the use of the corridor remains ongoing .
” Source location David John Smart · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue action to improve patient flow across the urgent and emergency care pathway.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue action to expand available urgent and emergency care capacity.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide focused support to the most challenged trusts.
Verbatim wording from the response “The Government and NHS England will continue to take action across the full urgent and emergency care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on accident and emergency departments. This includes focused support for the most challenged trusts, alongside strengthened reporting arrangements and the introduction of a consistent national definition of corridor care to support greater transparency. We will also begin publishing data on corridor care for the first time, subject to assurance of data quality.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen direct-to-specialty pathways and expand acceptance criteria for patients accepted directly by hospital specialties.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct inter-hospital referrals to inpatient beds rather than routing them through the Emergency Department.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a 24/7 medical Same Day Emergency Care unit to stream suitable patients away from the Emergency Department.
Verbatim wording from the response “The key workstreams include strengthening the ‘Direct to Specialty Pathways between the Emergency Department and the Trust’s specialties for patients who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore working with NEWTON to decompress the Emergency Department, strengthen Same Day Emergency Care, and improve flow for patients without a criteria to reside.
Verbatim wording from the response “The Trust is currently exploring working with a company (NEWTON) to increase the opportunity for decompressing the EDs, further strengthening the SDECs across the Trust, and improving flow once patients do not have a criteria to reside.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run Emergency Physician In Charge and corridor huddles continuously to review corridor patients, identify pathways, and escalate risks.
Verbatim wording from the response “All specialties in-reach to the ED and we operate a 3/2/1 bleep system to ensure this is fast and effective. We continue to run ‘Emergency Physician In Charge’ (EPIC) huddles and Corridor huddles multiple times a day 24/7 days a week. These allow line-by-line reviews of every patient in the corridor to ensure all appropriate pathways are considered; this is known as check and challenge and provides live escalation.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate and regularly review the Hospital Alternative Oversight Programme and its admission-avoidance, flow, discharge, virtual-care, frailty, therapy, and urgent-care initiatives.
Verbatim wording from the response “The Hospital Alternative Oversight Programme (HALO) is embedded in daily practice and continues to be reviewed regularly to ensure all opportunities are maximised. This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Collaborate with the local Mental Health Trust to secure timely mental health admission or avoid Emergency Department attendance.
Verbatim wording from the response “There continues to be ongoing collaborative work with the local Mental Health Trust, SPFT to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible or avoid ED attendance in the first place.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use ambulatory Emergency Department space effectively to maximise clinical capacity and reduce overcrowding.
Verbatim wording from the response “We continue to use ambulatory space as effectively as possible across the ED to maximise clinical space and reduce overcrowding.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medicine Division’s Continuous Flow Model to move patients earlier from the Acute Floor and reduce Emergency Department admission waits.
Verbatim wording from the response “The Continuous Flow Model is embedded within the Medicine Division and continues to ensure earlier movement of patients from the Acute Floor and reducing the time patients are waiting in the ED for admission to a ward. There are ongoing discussions with clinical Divisions outside the Medicine Division to implement a similar model.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement local corridor-care safety measures, including digital observations and prescribing, intentional rounding, corridor standards, high-risk reviews, and dedicated monitoring space.
Verbatim wording from the response “We recognise that the contributory factors leading to corridor care are multi-faceted and complex. As these issues involve a multi-agency approach, working alongside our system partners, we acknowledge that eradicating care in non-clinical environments will take considerable time. Therefore, alongside these actions, the ED team is continuing to implement local measures to improve the quality and safety for patients receiving care in these areas. Examples of these are:” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete phase one of the Acute Floor Reconfiguration programme, including opening the new Acute Medical Unit and 24/7 Medical Same Day Emergency Care unit.
Verbatim wording from the response “Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the Urgent and Emergency Care Plan and Medium-Term Planning Framework setting national expectations to eliminate corridor care.
Verbatim wording from the response “Since your previous Reports to us, the NHS England Urgent and Emergency Care Plan for 2025/26 has been published (in June 2025) and supported by the Medium-Term Planning Framework, which sets out a national expectation that systems take coordinated action to eliminate corridor care by improving end-to-end patient flow, reducing avoidable hospital congestion and improving timely discharge from hospital.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support providers and Integrated Care Boards to improve hospital flow through faster senior decisions, same-day emergency care and virtual wards.
Verbatim wording from the response “Alongside this, NHS England has been and continues to support providers and Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior clinical decision-making, increased use of same day emergency care and virtual wards, and more effective management of patient pathways. The plan also aims to reduce demand on emergency departments through improved access to community and primary care alternatives and strengthened admission avoidance pathways, so that patients can be assessed and treated in the most appropriate setting.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support providers and Integrated Care Boards to reduce emergency-department demand through community and primary-care alternatives and strengthened admission-avoidance pathways.
Verbatim wording from the response “Alongside this, NHS England has been and continues to support providers and Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior clinical decision-making, increased use of same day emergency care and virtual wards, and more effective management of patient pathways. The plan also aims to reduce demand on emergency departments through improved access to community and primary care alternatives and strengthened admission avoidance pathways, so that patients can be assessed and treated in the most appropriate setting.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support providers and Integrated Care Boards to strengthen discharge processes through criteria-led discharge and discharge-to-assess models.
Verbatim wording from the response “A key element of improving patient flow is reducing delays in discharging patients who no longer require acute hospital treatment. Delayed discharges contribute to high bed occupancy, reducing capacity for emergency admissions and increasing pressure on emergency departments. NHS England is supporting providers and ICBs to strengthen” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop Model Discharge guidance to reduce discharge delays and improve patient flow.
Verbatim wording from the response “discharge processes, including through the consistent use of criteria-led discharge and discharge to assess models. NHS England is also developing “Model Discharge” guidance to support trusts in reducing delays and improving patient flow.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide targeted regional support to systems experiencing the highest levels of patient-flow pressure.
Verbatim wording from the response “To strengthen oversight and drive improvement, NHS England is working through regional teams to provide targeted support to systems experiencing the highest levels of flow pressure. From May 2026, the routine publication of corridor care data has begun, increasing transparency and enabling more focused intervention where risks to patient safety are greatest.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish corridor-care data routinely to increase transparency and enable focused intervention where patient-safety risks are greatest.
Verbatim wording from the response “To strengthen oversight and drive improvement, NHS England is working through regional teams to provide targeted support to systems experiencing the highest levels of flow pressure. From May 2026, the routine publication of corridor care data has begun, increasing transparency and enabling more focused intervention where risks to patient safety are greatest.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for directly addressing the concerns about corridor care and providing the full response.
Verbatim wording from the response “In considering your report, officials within the Department of Health and Social Care have made enquiries with NHS England and concluded that these concerns are more appropriately addressed by NHS England directly. I am advised that NHS England will therefore provide you with a full and comprehensive response on the concerns you have raised.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust cannot eradicate corridor care without all partner organisations working together to address the wider system problem.
Verbatim wording from the response “The use of Emergency Department (ED) corridors to care for patients is a significant national problem. The Executive team is working closely with very senior members of the local ICB (Integrated Care Board), CQC (Care Quality Commission), local mental health Trust, and social care providers to tackle the problem. As a Trust we cannot solve the problem without all partner organisations working together. I am so sorry you have had the need to write to us again with your concerns and I too share these concerns.” Source location Response from University Hospitals Sussex NHS Foundation Trust
Open published response
17 Dec 2025 Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Insufficient A&E staffing to manage demand during busy periods View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department of Health and Social Care
Invest £250 million to expand same-day and urgent care services and support faster diagnosis, treatment and discharge.
View source
Department of Health and Social Care
Increase urgent care delivered in primary, community and mental health settings.
View source
Department of Health and Social Care
Increase urgent care capacity outside hospitals through new neighbourhood health services.
View source
Department of Health and Social Care
Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
View source See 1 more action
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AI-generated summary
Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Dr Debapriya Ghosh and Mr David Albert Ward died at St George’s Hospital after falls causing traumatic head injuries while they were being treated in a busy A&E department. The report raised concerns about insufficient staffing and resources, inadequate nursing risk assessment and supervision, reliance on families to supervise patients, and the resulting risks in overcrowded A&E departments.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient A&E staffing to manage demand during busy periods
Wider context from the report “1. That St George’s Hospital and other hospital A&E departments have insufficient staff to manage demand during busy periods such that nursing risk cannot be managed without relying on families .
” Source location Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest £250 million to expand same-day and urgent care services and support faster diagnosis, treatment and discharge.
Verbatim wording from the response “• Investing £250 million into expanding same day and urgent care services, helping avoid unnecessary admissions to hospital and supporting faster diagnosis, treatment and discharge for patients.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase urgent care delivered in primary, community and mental health settings.
Verbatim wording from the response “• Increasing the number of patients receiving urgent care in primary, community and mental health settings.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase urgent care capacity outside hospitals through new neighbourhood health services.
Verbatim wording from the response “• In the longer-term, our 10 Year Health Plan will increase the urgent care capacity outside hospital through new neighbourhood health services, reducing demand pressures on A&E.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
Verbatim wording from the response “• Improve hospital flow, with a focus on reducing the number of patients waiting more than 12 hours and making progress towards eliminating corridor care.” Source location Response from Department for Health and Social Care
Open published response
4 Dec 2025 Lina Piroli · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Insufficient A&E nursing capacity for patient numbers View source Failure of A&E environments to provide appropriate care for elderly and complex medical patients View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
NHS England
Publish the 2025/26 Urgent and Emergency Care Plan to improve hospital flow, reduce prolonged waits and eliminate corridor care.
View source
NHS England
Work with regions to support acute trusts in eliminating emergency-department crowding through improved patient flow and length of stay.
View source
NHS England
Continue developing services that shift unplanned urgent care outside acute hospitals, support alternatives to admission and improve discharge.
View source
Department of Health and Social Care
Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
View source See 1 more action
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AI-generated summary
Lina Piroli · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient A&E nursing capacity for patient numbers
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Source location Lina Piroli · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of A&E environments to provide appropriate care for elderly and complex medical patients
Wider context from the report “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old.
Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment . It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery.
I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require . Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care.
” Source location Lina Piroli · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025/26 Urgent and Emergency Care Plan to improve hospital flow, reduce prolonged waits and eliminate corridor care.
Verbatim wording from the response “Recognising that there is further work to be done, in June 2025, NHS England published the Urgent and Emergency Care Plan for 2025/26 which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regions to support acute trusts in eliminating emergency-department crowding through improved patient flow and length of stay.
Verbatim wording from the response “working with the regions to support Acute Trusts to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s operational planning guidance, where Integrated Care Boards (ICBs) were asked to focus on delivering improved patient flow. This has included increasing the productivity of acute and non-acute healthcare services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue developing services that shift unplanned urgent care outside acute hospitals, support alternatives to admission and improve discharge.
Verbatim wording from the response “working with the regions to support Acute Trusts to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s operational planning guidance, where Integrated Care Boards (ICBs) were asked to focus on delivering improved patient flow. This has included increasing the productivity of acute and non-acute healthcare services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
Verbatim wording from the response “• Improve hospital flow, with a focus on reducing the number of patients waiting more than 12 hours and making progress towards eliminating corridor care.” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 1
Failure to provide sufficient designated clinical space for Emergency Department patients View source
Linked responses
Department of Health and Social Care NHS England University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 27
Department of Health and Social Care
Publish data on the prevalence of corridor care to improve transparency and drive improvement.
View source
University Hospitals Sussex NHS Foundation Trust
Progress the Acute Floor Reconfiguration capital programme to improve patient flow, capacity, and the clinical environment.
View source
University Hospitals Sussex NHS Foundation Trust
Implement a hospital-wide no-corridor culture through nominated leaders, staff empowerment, rapid response, feedback, learning, recognition, and scenario-based training.
View source
University Hospitals Sussex NHS Foundation Trust
Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.
View source
University Hospitals Sussex NHS Foundation Trust
Lead the Hospital Alternative Oversight Programme to reduce inappropriate admissions and improve hospital flow and discharge through alternative-care, urgent-treatment, same-day, virtual, frailty, therapy, planning, and acuity initiatives.
View source
University Hospitals Sussex NHS Foundation Trust
Provide consultant advice to ambulance services at the point of contact to support appropriate emergency-department referrals and avoid unnecessary attendances.
View source
University Hospitals Sussex NHS Foundation Trust
Coordinate with the local mental health trust to support rapid admission of patients requiring mental health care to appropriate units.
View source
University Hospitals Sussex NHS Foundation Trust
Educate high-presenting nursing homes about avoiding unnecessary emergency-department attendances and navigating alternative care.
View source
University Hospitals Sussex NHS Foundation Trust
Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.
View source
University Hospitals Sussex NHS Foundation Trust
Convert a trolley cubicle into a reclining-chair area in the emergency department to increase clinical space.
View source
University Hospitals Sussex NHS Foundation Trust
Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce emergency-department waits for ward admission.
View source
NHS England
Publish principles for providing safer care in Temporary Escalation Spaces when demand exceeds capacity.
View source
NHS England
Develop the operating model supporting providers to eliminate emergency-department crowding and corridor care.
View source
NHS England
Progress patient-flow improvements through Operational Planning guidance, including productivity, reduced length of stay and improved clinical outcomes.
View source
NHS England
Develop services that shift unplanned urgent activity from acute hospitals to alternative settings and support proactive care and discharge.
View source
NHS England
Mandate daily reporting of Temporary Escalation Space use by acute hospitals in emergency departments and wards.
View source
NHS England
Work with regional teams to improve the quality, timeliness and completeness of Temporary Escalation Space data.
View source
NHS England
Publish Temporary Escalation Space usage data during 2025/26 to drive reductions in corridor care.
View source
University Hospitals Sussex NHS Foundation Trust
Deliver the Acute Floor Reconfiguration capital programme to improve capacity, patient flow and the clinical environment.
View source
University Hospitals Sussex NHS Foundation Trust
Lead a hospital-wide no-corridor culture programme using nominated leaders, staff empowerment, response targets, feedback, recognition and scenario-based training.
View source
University Hospitals Sussex NHS Foundation Trust
Operate the Direct to Specialty Pathway Agreement, supported by specialty in-reach, rapid bleep escalation, daily referral monitoring and cross-specialty flow meetings.
View source
University Hospitals Sussex NHS Foundation Trust
Lead the Hospital Alternative Oversight Programme to avoid inappropriate admissions, improve hospital flow and smooth discharge through alternative-care and same-day emergency initiatives.
View source
University Hospitals Sussex NHS Foundation Trust
Provide Trust consultant advice at ambulance point of contact with SECAmb to direct only patients requiring emergency care to the ED.
View source
University Hospitals Sussex NHS Foundation Trust
Educate teams at ten local nursing homes about avoidable ED attendances and alternatives to ED care.
View source
University Hospitals Sussex NHS Foundation Trust
Realign bed spaces and matching workforce through capacity-and-demand modelling.
View source
University Hospitals Sussex NHS Foundation Trust
Convert a trolley cubicle into a reclining-chair area in ED Majors to increase clinical space.
View source
University Hospitals Sussex NHS Foundation Trust
Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce ED waits for ward admission.
View source See 24 more actions
×
AI-generated summary
Maureen Brenda Batchelor · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maureen Brenda Batchelor was admitted to hospital with diarrhoea and vomiting, was diagnosed with gastroenteritis and aspiration pneumonia, and died on 26 February 2025 from septicaemia caused by aspiration pneumonia. The report raised concerns that patients were being treated in the Emergency Department corridor, a non-clinical area, because of insufficient capacity, with this practice continuing and no evidence as to when it would end.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide sufficient designated clinical space for Emergency Department patients
Wider context from the report “During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area.
I understand that at the time of Mrs Batchelor's attendance on 25 February there were 25 patients in the Emergency Department corridor, and this increased to 32 patients.
Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. When asked there was no evidence as to when this practice would no longer be necessary.
I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to treat patients and the only other alternative would be to hold patients in ambulances outside of the hospital.
A Prevention of Future Deaths report in relation to the use of the corridor for patient care was made during an investigation into a death which occurred in December 2022 and the use of the corridor remains ongoing.
” Source location Maureen Brenda Batchelor · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish data on the prevalence of corridor care to improve transparency and drive improvement.
Verbatim wording from the response “Regarding your concerns on corridor care, the provision of clinical care in corridors is unacceptable. We will publish data on the prevalence of corridor care for the first time to support transparency and drive improvement. NHS England has been working with trusts since 2024 to put in place new reporting arrangements. The data quality is currently being reviewed, and we expect to publish the information shortly.” Source location Response from Department for Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress the Acute Floor Reconfiguration capital programme to improve patient flow, capacity, and the clinical environment.
Verbatim wording from the response “As you know from the evidence heard at the inquest, the Medicine Divisional Leadership team, the Hospital Directors, and Executive team are continuously working on several separate but linked workstreams, which were previously in their infancy, to eradicate the use of the ED corridor for patient care and ensure they are treated in the most appropriate clinical environment with dignity and without delays.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a hospital-wide no-corridor culture through nominated leaders, staff empowerment, rapid response, feedback, learning, recognition, and scenario-based training.
Verbatim wording from the response “Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.
Verbatim wording from the response “We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead the Hospital Alternative Oversight Programme to reduce inappropriate admissions and improve hospital flow and discharge through alternative-care, urgent-treatment, same-day, virtual, frailty, therapy, planning, and acuity initiatives.
Verbatim wording from the response “We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide consultant advice to ambulance services at the point of contact to support appropriate emergency-department referrals and avoid unnecessary attendances.
Verbatim wording from the response “I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8 -10 ambulance attendances are avoided each day.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Coordinate with the local mental health trust to support rapid admission of patients requiring mental health care to appropriate units.
Verbatim wording from the response “Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Educate high-presenting nursing homes about avoiding unnecessary emergency-department attendances and navigating alternative care.
Verbatim wording from the response “One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.
Verbatim wording from the response “There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convert a trolley cubicle into a reclining-chair area in the emergency department to increase clinical space.
Verbatim wording from the response “We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce emergency-department waits for ward admission.
Verbatim wording from the response “The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.” Source location 2025-0406 - Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish principles for providing safer care in Temporary Escalation Spaces when demand exceeds capacity.
Verbatim wording from the response “The delivery of care in Temporary Escalation Spaces (TES) in EDs experiencing patient crowding (including providing care at beds and chairs) is not acceptable and should not be considered as standard. TES refers to care given in any unplanned settings (such as corridors) and, in September 2024, NHS England published a set of principles for supporting improved quality of care should patient demand outstrip capacity. These principles have been developed to support point-of-care staff to provide the safest, most effective and highest quality care possible when TES care has been deemed necessary, and the principles should be applied alongside any local standard operating procedures and arrangements governing flow pathways and safe staffing.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop the operating model supporting providers to eliminate emergency-department crowding and corridor care.
Verbatim wording from the response “In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress patient-flow improvements through Operational Planning guidance, including productivity, reduced length of stay and improved clinical outcomes.
Verbatim wording from the response “In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop services that shift unplanned urgent activity from acute hospitals to alternative settings and support proactive care and discharge.
Verbatim wording from the response “are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate daily reporting of Temporary Escalation Space use by acute hospitals in emergency departments and wards.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with regional teams to improve the quality, timeliness and completeness of Temporary Escalation Space data.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish Temporary Escalation Space usage data during 2025/26 to drive reductions in corridor care.
Verbatim wording from the response “Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Acute Floor Reconfiguration capital programme to improve capacity, patient flow and the clinical environment.
Verbatim wording from the response “Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County Hospital, is well underway.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead a hospital-wide no-corridor culture programme using nominated leaders, staff empowerment, response targets, feedback, recognition and scenario-based training.
Verbatim wording from the response “Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Direct to Specialty Pathway Agreement, supported by specialty in-reach, rapid bleep escalation, daily referral monitoring and cross-specialty flow meetings.
Verbatim wording from the response “We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Lead the Hospital Alternative Oversight Programme to avoid inappropriate admissions, improve hospital flow and smooth discharge through alternative-care and same-day emergency initiatives.
Verbatim wording from the response “We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Trust consultant advice at ambulance point of contact with SECAmb to direct only patients requiring emergency care to the ED.
Verbatim wording from the response “I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8-10 ambulance attendances are avoided each day.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Educate teams at ten local nursing homes about avoidable ED attendances and alternatives to ED care.
Verbatim wording from the response “One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Realign bed spaces and matching workforce through capacity-and-demand modelling.
Verbatim wording from the response “There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convert a trolley cubicle into a reclining-chair area in ED Majors to increase clinical space.
Verbatim wording from the response “We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce ED waits for ward admission.
Verbatim wording from the response “The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.” Source location Response from Hospital Trust
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for addressing the concerns and has already provided a response.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and I understand they have already responded to address your concerns.” Source location Response from Department for Health and Social Care
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Compromised emergency department capacity to meet physically ill patients' needs View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Epsom and St Helier University Hospitals NHS Trust NHS Southwest London Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
Epsom and St Helier University Hospitals NHS Trust
Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
View source
Epsom and St Helier University Hospitals NHS Trust
Use an emergency-department risk-assessment process to identify patients needing majors-area capacity and move others to Same Day Emergency Care.
View source
Epsom and St Helier University Hospitals NHS Trust
Participate in the Surrey collaborative national quality-improvement programme to improve emergency-department flow for high-intensity users.
View source
Department of Health and Social Care
Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
View source
Department of Health and Social Care
Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
View source
Department of Health and Social Care
Provide 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
View source
Department of Health and Social Care
Deliver more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
View source
NHS Southwest London Integrated Care Board
Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
View source
NHS Southwest London Integrated Care Board
Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
View source
Department of Health and Social Care
Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
View source
Department of Health and Social Care
Provide 24-hour access to trained NHS professionals through the NHS 111 mental health option, with assessment and onward access to community or alternative crisis services.
View source
Department of Health and Social Care
Transform mental health crisis care into community-based 24/7 neighbourhood mental health centres with integrated crisis services, community services and short-stay beds.
View source See 9 more actions
×
AI-generated summary
Tracey Ostler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Source location Tracey Ostler · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
Verbatim wording from the response “The Trust works collaboratively with SABP to ensure that these delays are kept to a minimum. Every patient awaiting psychiatric admission is subject to daily escalation through Trust site meetings and concerns are raised with SABP and the ICB. Executive led weekly meetings between the Trust and SABP provides further oversight of plans for mental health patients at the Trust. The Trust continues to advocate for timely transfer to inpatient psychiatric units recognising that ED cannot provide the ward-based, multidisciplinary care these patients require.” Source location Response from Epsom General Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an emergency-department risk-assessment process to identify patients needing majors-area capacity and move others to Same Day Emergency Care.
Verbatim wording from the response “To mitigate the impact of this, the following initiatives have been introduced:” Source location Response from Epsom General Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the Surrey collaborative national quality-improvement programme to improve emergency-department flow for high-intensity users.
Verbatim wording from the response “• Epsom ED have signed up to a national quality improvement (QI) programme as a Surrey collaborative (through the Mind and Body programme) to look at” Source location Response from Epsom General Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
Verbatim wording from the response “We will also continue to work closely with stakeholders to consider how we can support those experiencing a mental health crisis in A&E, as well as wider actions to improve care to prevent people reaching crisis point or, where they do, creating better community-based alternatives to A&E.” Source location Response from Department for Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Verbatim wording from the response “This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
Verbatim wording from the response “Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such as organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission.” Source location Response from Department for Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
Verbatim wording from the response “As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds.” Source location Response from Department for Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
Verbatim wording from the response “SW London works closely with SWLSTG to address delays in the urgent care pathway and minimise delays in access to beds. This work is focused on both improving the inpatient pathway and maximising use of crisis alternatives where appropriate and able to meet patient needs. Such services include the 24/7 crisis lines, ‘111 press 2 for mental health service’, community-based crisis cafés, and Home Treatment Teams.” Source location Response from NHS South West London Integrated Care Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
Verbatim wording from the response “The outputs of this work will identify gaps within current pathways and support future commissioning plans, including winter planning. It will also provide tailored improvement plans aimed at enhancing mental healthcare delivery within SWLSTG and reducing demand and delays in emergency departments across SW London.” Source location Response from NHS South West London Integrated Care Board
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Verbatim wording from the response “This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide 24-hour access to trained NHS professionals through the NHS 111 mental health option, with assessment and onward access to community or alternative crisis services.
Verbatim wording from the response “Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such as organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transform mental health crisis care into community-based 24/7 neighbourhood mental health centres with integrated crisis services, community services and short-stay beds.
Verbatim wording from the response “As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds.” Source location Response from Department for Health and Social Care
Open published response
9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient emergency-department bed capacity causing delays in patient transfer View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Bernard Lyon · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient emergency-department bed capacity causing delays in patient transfer
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
” Source location Bernard Lyon · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC relies on ongoing monitoring, performance data and targeted inspections for emergency services rather than additional action on emergency-department resourcing.
Verbatim wording from the response “Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect” Source location Response from CQC
Open published response
Concerns raised 1
ED crowding delaying patient access to surgery or specialist treatment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.
View source
Department of Health and Social Care
Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
View source
Department of Health and Social Care
Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
View source
Department of Health and Social Care
Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
View source
Department of Health and Social Care
Set out lessons learned from winter urgent and emergency care pressures.
View source
Department of Health and Social Care
Put improvements in place to further improve urgent and emergency care services during 2025/26.
View source See 3 more actions
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AI-generated summary
Andrew Waters · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation ED crowding delaying patient access to surgery or specialist treatment
Wider context from the report “(2) ED crowding leading to increased risk in mortality for patients being held in ambulances and corridors and being delayed from receiving surgery or specialist treatment on wards .
” Source location Andrew Waters · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.
Verbatim wording from the response “On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.” Source location Response from DHSC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
Verbatim wording from the response “Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.” Source location Response from DHSC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays.” Source location Response from DHSC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
Verbatim wording from the response “In January 2025, we also published a new policy framework for the £9 billion Better Care Fund. Under the new framework, the NHS and local authorities have clear accountability for setting and achieving joint goals that include reducing discharge delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out lessons learned from winter urgent and emergency care pressures.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put improvements in place to further improve urgent and emergency care services during 2025/26.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
Open published response
13 Mar 2025 Billie Diane WICKS · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Understaffing of the emergency department, including insufficient staff to take basic observations View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Royal College of Emergency Medicine Royal College of Paediatrics and Child Health Royal Free London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Royal Free London NHS Foundation Trust
Maintain augmented paediatric consultant cover from 09:00 to 23:00 on weekdays.
View source
Royal Free London NHS Foundation Trust
Provide augmented medical and nursing staffing, including a 24/7 Emergency Department Assistant, using bank and agency cover pending establishment approval.
View source
Royal Free London NHS Foundation Trust
Review the business case for a Clinical Practice Educator, Emergency Department Assistant and additional paediatric emergency-department nursing establishment.
View source
Royal Free London NHS Foundation Trust
Review day and night emergency-department staffing skill mix.
View source
Royal College of Paediatrics and Child Health
Conducted work to identify where paediatric rota gaps most significantly affect services.
View source
Royal College of Paediatrics and Child Health
Continue advocating locally and nationally for active reduction of paediatric rota gaps.
View source See 3 more actions
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AI-generated summary
Billie Diane WICKS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Understaffing of the emergency department, including insufficient staff to take basic observations
Wider context from the report “1. At inquest, I heard repeatedly that on the night Billie attended, the Royal Free emergency department was understaffed, and that it remains understaffed of doctors, nurses, and even a healthcare assistant who could take basic observations .
Billie should have had observations every hour. If she had had these observations, the emergency registrar who discharged her would have recognised that she was not as well as he thought, and would have sought senior medical review. That senior medical review would have changed the course of her management and saved her life.
Following the inquest touching on the death of Daniel Klosi, I wrote to you on 16 August 2024 about a lack of observations in the emergency department of the Royal Free. Although the circumstances were different, there is a theme.
” Source location Billie Diane WICKS · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain augmented paediatric consultant cover from 09:00 to 23:00 on weekdays.
Verbatim wording from the response “• Emergency department paediatric consultant cover has been augmented since this incident and is now consistently scheduled every day between 09:00 - 23:00 hrs Monday to Friday, providing senior supervision during these hours to the middle grade doctors working in this area, maintaining robust training and guidance during these hours to enable improved decision making and increased confidence overnight.” Source location Response from Royal Free Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide augmented medical and nursing staffing, including a 24/7 Emergency Department Assistant, using bank and agency cover pending establishment approval.
Verbatim wording from the response “• Nurse staffing on the night of Billie’s first attendance on 14th September 2024 was in line with the nursing establishment levels of safe staffing except for one Registered Nurse (RN) rota gap during the day shift prior to Billie’s attendance. In the interim the trust has approved additional staffing to medical and nursing shifts, filled by bank and agency staff to mitigate staffing to the levels described in the business case based on safe staffing skill mix assessment and the level of acuity / complexity of patients attending in the Royal Free Hospital emergency department.” Source location Response from Royal Free Hospitals
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the business case for a Clinical Practice Educator, Emergency Department Assistant and additional paediatric emergency-department nursing establishment.
Verbatim wording from the response “• Long-term mitigation of the current establishment is anticipated and is associated with the trusts process of business case approval. However, in the interim we are achieving the augmented staffing levels with bank and agency shift cover until we have the reconfigured and augmented establishment approved. This will increase the number of senior staff on shift as well as supplement the paediatric team with an Emergency Department Assistant (EDA) 24/7. This is a non-registered clinical member of staff who can take on duties similar to a Health Care Assistant/Support Worker including performing and recording observations on paediatric patients.” Source location Response from Royal Free Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review day and night emergency-department staffing skill mix.
Verbatim wording from the response “2. Senior matron for Emergency Department to review staffing skill mix for day and night shifts. | Senior matron, Emergency Department | 30/05/2025 | Copy of the business plan” Source location Response from Royal Free Hospitals
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conducted work to identify where paediatric rota gaps most significantly affect services.
Verbatim wording from the response “From the information provided we do not know many observations (if any) Billie had during her five hour stay in ED. Observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtainable, however RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas resulting in understaffed departments. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact paediatrics, and we continue to advocate at a local and national level for an active reduction in these gaps¹.” Source location Response from Royal College of Paediatrics and Child Health
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue advocating locally and nationally for active reduction of paediatric rota gaps.
Verbatim wording from the response “From the information provided we do not know many observations (if any) Billie had during her five hour stay in ED. Observations are important but are part of a holistic assessment of children. There are lots of reasons why observations might not be obtainable, however RCPCH recognises that challenges are significantly exacerbated by gaps in clinical rotas resulting in understaffed departments. In 2024, RCPCH carried out work to better understand where rota gaps most prominently impact paediatrics, and we continue to advocate at a local and national level for an active reduction in these gaps¹.” Source location Response from Royal College of Paediatrics and Child Health
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nursing staffing was in line with safe establishment levels, apart from one registered-nurse rota gap before Billie’s attendance.
Verbatim wording from the response “• Nurse staffing on the night of Billie’s first attendance on 14th September 2024 was in line with the nursing establishment levels of safe staffing except for one Registered Nurse (RN) rota gap during the day shift prior to Billie’s attendance. In the interim the trust has approved additional staffing to medical and nursing shifts, filled by bank and agency staff to mitigate staffing to the levels described in the business case based on safe staffing skill mix assessment and the level of acuity / complexity of patients attending in the Royal Free Hospital emergency department.” Source location Response from Royal Free Hospitals
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The response cannot comment on the hospital emergency department’s staffing model, staffing numbers or skill mix.
Verbatim wording from the response “Staffing
We are unable to comment about the staffing model, numbers, or skill mix, at The Royal Free Hospital’s emergency department. The Royal College of Emergency Medicine (RCEM) has guidance regarding the level of staffing for doctors [1], nurses, and healthcare staff [2]. In December 2024, the RCEM also published standards around staffing [3], [7]. Each ED should have a senior decision-making (tier 4) doctor in the department at all times [3, 7]. A tier 4 doctor may be referred to as a registrar. Adequate staffing is required to deliver safe care.” Source location Response from Royal College of Emergency Medicine
Open published response
19 Feb 2025 Kenneth James CLAYTON · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient availability of ward beds for Emergency Department patient flow View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kenneth James CLAYTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of ward beds for Emergency Department patient flow
Wider context from the report “3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds . The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge.
” Source location Kenneth James CLAYTON · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.