Recurring concern

Insufficient emergency-department capacity for timely patient care

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First reported 17 May 2017•Latest report 18 Jun 2026

Definition

What this concern includes

Includes recurring deficiencies in emergency-department beds, clinical space, staffing or directly related capacity arrangements when they leave the department unable to accommodate demand or provide timely patient care, including the anchor's lack of bed capacity and recurring high-demand capacity pressures.

Not included

Excludes general hospital, ward or critical-care capacity shortages unless they directly cause insufficient emergency-department capacity.
Excludes ambulance handover, hospital admission, discharge, bed-management or patient-flow failures where emergency-department capacity is not itself the unsafe condition.
Excludes excessive waiting-time assertions when no underlying emergency-department capacity deficiency is identified.
Excludes isolated overcrowding or a single busy period without evidence of a continuing or recurring emergency-department capacity problem.

Reports: 28
Individual concerns: 34
Date range: 2017–2026
Stated actions: 193

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care20

NHS England9

University Hospitals Sussex NHS Foundation Trust3

Betsi Cadwaladr University LHB2

Greater Manchester Health and Social Care Partnership2

Blackpool Teaching Hospitals NHS Foundation Trust1

Care Quality Commission1

Conwy County Borough Council1

Cwm Taf Morgannwg University Local Health Board1

Denbighshire County Council1

Epsom Hospital1

Flintshire County Council1

Health and Care Professions Council1

Health Services Safety Investigations Body1

NHS Norfolk and Suffolk Integrated Care Board1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

14 Sep2022
Manchester South
Concerns raised1
1. Lack of emergency department bed capacity
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement an enhanced bed-allocation pathway to identify hip-fracture patients and support timely transfer from the Emergency Department to trauma and orthopaedics beds.
  Stated by NHS EnglandStated completed
AI-generated summary

Maureen Harrop · 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 Harrop, a care home resident, suffered an accidental fall resulting in a fracture to the neck of her femur. She experienced prolonged waits in the Emergency Department and for surgery, which was delayed because of limited bed and theatre capacity. She later developed a urinary tract infection, deteriorated, and died from urosepsis; the report raised concerns about the impact of these delays on her condition.

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
Lack of emergency department bed capacity
Wider context from the report
“1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity. The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her; ”
Source location
Maureen Harrop · Prevention of Future Deaths report
Page 2 · concerns
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
Implement an enhanced bed-allocation pathway to identify hip-fracture patients and support timely transfer from the Emergency Department to trauma and orthopaedics beds.

Verbatim wording from the response
“The Surgical and Medical Division have worked closely together to design and implement an enhanced bed allocation process. The process supports those patients with hip fractures from the moment that the patient has had their fracture confirmed in the ED, through to admission to a trauma and orthopaedics bed. The pathway redesign has included both in and out of hours actions required by the clinical teams, with support from the Trust’s patient flow team. Each Trust bed meeting, which occurs five times per day, highlights any patient within the ED who will require a Trauma and Orthopaedic bed due to a hip fracture.”

Source location
Response from NHS England
Page 2 · response
Published 5 October 2022
Open published response
6 Jan2022
Norfolk
Concerns raised4
1. Lack of emergency department capacity for timely ambulance patient transfer
2. Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
3. Limited capacity for diagnosis and treatment while patients wait in ambulances
1. Reliance on safety checks for patients left in ambulances because of emergency department space delays
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 18
1. Action
  Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
2. Action
  Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
3. Action
  Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
1. Action
  Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
2. Action
  Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
3. Action
  Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
4. Action
  Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
5. Action
  Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
6. Action
  Deliver six new ambulance hubs to reduce handover delays.
  Stated by Department of Health and Social CareStated in progress
7. Action
  Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.
  Stated by Department of Health and Social CareStated in progress
8. Action
  Provide 5,000 additional staffed permanent hospital beds.
  Stated by Department of Health and Social CareStated planned
9. Action
  Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.
  Stated by Department of Health and Social CareStated in progress
10. Action
  Establish Same Day Emergency Care services across every hospital with a major emergency department.
  Stated by Department of Health and Social CareStated planned
11. Action
  Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
12. Action
  Deliver the Leading for System Change project to identify and address system-wide discharge barriers.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
13. Action
  Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
14. Action
  Scale up virtual ward capacity beyond its existing level.
  Stated by Department of Health and Social CareStated planned
15. Action
  Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
Respondent positions 3
1. Position
  The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
1. Position
  Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
2. Position
  Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
AI-generated summary

Kyriacos Athanasis · 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

Kyriacos Athanasis, an 88-year-old man with frailty and several medical conditions, fell down stairs and sustained an unstable cervical spine fracture. Delays transferring him from an ambulance and diagnosing the fracture were followed by pneumonia, and he died after deteriorating. The principal concerns were emergency department overcrowding, insufficient ambulance patient safety checks, delayed diagnosis and treatment, and resulting risks to patients awaiting ambulance transfer or care.

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
Lack of emergency department capacity for timely ambulance patient transfer
Wider context from the report
“(1) Evidence given at the inquest revealed that there was a delay in Mr. Athanasis being transferred from the ambulance into the emergency department at the James Paget hospital as they had no space for him to be transferred into. ”
Source location
Kyriacos Athanasis · Prevention of Future Deaths report
Page 1 · concerns
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 to maintain emergency department and inpatient capacity for timely ambulance admissions
Wider context from the report
“(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner. ”
Source location
Kyriacos Athanasis · Prevention of Future Deaths report
Page 2 · concerns
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
Limited capacity for diagnosis and treatment while patients wait in ambulances
Wider context from the report
“(5) Significant local steps have been taken to reduce the risks to patients, but the department is functioning well over their capacity (at the time of the hearing the Trust had 75 patients in a department designed for 40). There are clear risks of future deaths for patients waiting for an ambulance as well as to patients whose diagnosis and treatment is delayed due to limited intervention being available in the back of an ambulance. ”
Source location
Kyriacos Athanasis · Prevention of Future Deaths report
Page 2 · concerns
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
Reliance on safety checks for patients left in ambulances because of emergency department space delays
Wider context from the report
“(2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed. ”
Source location
Kyriacos Athanasis · Prevention of Future Deaths report
Page 2 · concerns
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
Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.

Verbatim wording from the response
“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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 the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.

Verbatim wording from the response
“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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
Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.

Verbatim wording from the response
“Since May 2022 the ICB has supported all 3 acute hospitals within our system, including the JPUH, to further develop and expand its GP Streaming Unit which provides a pathway for ED staff to assess patient needs on arrival and ensure that those who are more suitable for GP care can attend the unit co-located within the department. This helps to create flow and promote more prompt clinical assessment.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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
Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.

Verbatim wording from the response
“In addition to the above, the ICB has continued to support provider-level actions to increase oversight of patients in waiting ambulances, enabling collaboration between ambulance and hospital providers to put in place new ways of working to maintain patient safety, that transcend traditional organisational responsibilities. For example, this includes a ‘pit-stop’ assessment model that came into effect at JPUH in June 2022, which enables early diagnostics to be commenced for patients before they enter the ED. This initiative was supported by the use of additional temporary staff including the use of reservists, additional bank staff and medical”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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
Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.

Verbatim wording from the response
“The ICB has focussed resources into the expansion of Same Day Emergency Care (SDEC) provision across all acute hospital sites as an alternative to ED attendance. This is an additional service which provides an alternative pathway for patients who require diagnostics and assessment, which can be undertaken without an overnight stay or prolonged hospital attendance.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023
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 the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.

Verbatim wording from the response
“The ICB is coordinating the system Discharge Programme which brings providers together to collaborate on the utilisation of this money; jointly planning, delivering, and monitoring improvement actions, including:”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
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
Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.

Verbatim wording from the response
“However, since August 2022 the NHS has released additional money for investment in discharge resources. In the first allocation the Norfolk and Waveney system was awarded £9m revenue and £2m capital, which was invested in new health and social care beds and community packages of care creating the equivalent of approximately 250 beds. In mid-November 2022 the government announced a further £500m fund for health and social care, of which our system share was approximately £11m which is currently being used to commission additional care and support services to further ease the burden on hospital beds. A third award was announced in January 2023 providing a further £3.74m revenue to be spent by 31st March 2023.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
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 local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.

Verbatim wording from the response
“nationally. We continue to follow the national NHS Operational Pressure Escalation Level Framework to identify, escalate and respond to flow pressures across our system. The ICB continues to coordinate a programme of local improvement, which is built optimising and utilising the funding we have been allocated, to focus on the following local priorities:”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023
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 six new ambulance hubs to reduce handover delays.

Verbatim wording from the response
“We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023
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 42 new or upgraded hospital discharge lounges to support safe, timely discharge.

Verbatim wording from the response
“We are taking a number of steps to improve ambulance response times. Ambulance trusts are receiving an additional £200 million of funding this year to expand capacity and deliver new ambulances, helping patients receive the treatment they need. We are also delivering 6”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023
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 5,000 additional staffed permanent hospital beds.

Verbatim wording from the response
“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
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 dedicated funding for social care to reduce beds occupied by patients ready for discharge.

Verbatim wording from the response
“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
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
Establish Same Day Emergency Care services across every hospital with a major emergency department.

Verbatim wording from the response
“In addition, Same Day Emergency Care (SDEC) services will be in place across every hospital with a major emergency department, helping avoid unnecessary overnight stays in hospital. The SDEC model helps to reduce pressure on emergency departments because patients receiving SDEC can be rapidly assessed, diagnosed, and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
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
Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.

Verbatim wording from the response
“The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
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 Leading for System Change project to identify and address system-wide discharge barriers.

Verbatim wording from the response
“The ICB has also placed senior clinical staff in to our three Acute Hospitals for focussed periods of on-site support, to support the management of escalations in a timely manner. Not only does this provide additional operational support to frontline colleagues, utilising ICB staff experience, it also improves ICB oversight and assurance, enabling the ICB to actively reflect on the operational impact that their system-level interventions (as described above) are having on patients and the staff delivering their care. The Norfolk and Waveney ‘Leading for System Change’ project launched in 2022, bringing together key colleagues involved in discharge across the Integrated Care System (ICS) with a focussed remit to understand, mitigate and rectify some of our underlying problems as a system which include:”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
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 a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.

Verbatim wording from the response
“Additionally, following the formation of the Integrated Care Board (ICB) in July 2023, the Urgent and Emergency Care (UEC) Board was formalised within the ICB governance arrangements. Under Executive Director sponsorship the role of the UEC Board is to lead on the transformation and improvement work within our area. The Board membership includes system partners and is responsible for the implementation and oversight of several workstreams including:”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023
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
Scale up virtual ward capacity beyond its existing level.

Verbatim wording from the response
“A key part of the recovery plans is about improving hospital’s patient flow and bed capacity. The recovery plan will deliver 5,000 more staffed, permanent beds and scale up virtual ward beds which are now over 11,000. This increase is backed by £1 billion of dedicated revenue funding and £250m of capital funding. A further £1.6 billion of funding for social care over two years is being provided to reduce the numbers of beds occupied by patients ready to be discharged. These measures will speed up emergency admissions and reduce overcrowding in Emergency Departments enabling ambulances to handover patients more quickly.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
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 adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.

Verbatim wording from the response
“The ICB coordinated systemwide adoption in October 2022 of the Professional Standards of Care for Patients Waiting in Ambulances to ensure patients awaiting handover to ED receive consistent, timely and clinically appropriate care, and that processes are in place to rapidly identify and escalate care needs for deteriorating patients. The ICB continues to monitor compliance with these standards, through daily system calls and discussion with site teams, as well as focused on-site quality visits.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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
The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.

Verbatim wording from the response
“The ICB continues to commission the East of England Ambulance Service Trust to provide the Hospital Ambulance Liaison Officer (HALO) role at our three Acute Hospitals. The HALO works closely with hospital Site Managers and clinical staff, along with the ambulance Emergency Operational Control (EOC) room, to provide day to day co-ordination of emergency and ambulance staff in line with Trust policies and procedures to reduce ambulance turnaround times, prioritise patients for handover into ED and ensure that patients in the local communities receive the appropriate response to emergency calls. Additionally, the ICB has supported the early implementation of an ambulance ‘rapid release’ protocol, to enable crews waiting to handover to immediately release a patient into the care of the hospital to attend to a patient in the community, in a life-threatening condition.”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
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
Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.

Verbatim wording from the response
“Nationally, the NHS stopped the Hospital Discharge Fund on 31 March 2022, which had essentially funded 4 weeks of ‘free care’ to support patient discharge, regardless of who was responsible for commissioning this care and which also paid for a large range of services and beds. This meant that on 1st April the Norfolk and Waveney system lost funding for”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023
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
Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.

Verbatim wording from the response
“The success of this workstream is dependent on a whole system approach, but fundamentally relies on adequate social care provision so that patients can be discharged with a safe level of support that meets their needs and optimises their recovery and releablement post-hospital admission. The ICB has continued to fund additional social workers, to undertake Care Act assessments to enable discharge from recovery beds. We have also increased funding for additional domiciliary care and accessed external agencies to help provide this, to support patients to return home. To date, we have commissioned a number of new beds for pre-hospital”

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
23 Oct2021
Manchester South
Concerns raised1
1. Insufficient senior emergency department doctor staffing at night
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Margaret Kinsey · 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

Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.

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 senior emergency department doctor staffing at night
Wider context from the report
“1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced. As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care. ”
Source location
Margaret Kinsey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Jul2020
Manchester South
Concerns raised2
1. Lack of appropriate Emergency Department space for treating vulnerable patients
2. Failure to maintain sufficient Emergency Department capacity during recurring periods of high demand
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 13
1. Action
  Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.
  Stated by Department of Health and Social CareStated completed
1. Action
  Maintain Nightingale Hospitals and their surge capacity.
  Stated by Department of Health and Social CareStated completed
2. Action
  Maintain NHS use of independent-sector hospital capacity.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.
  Stated by Department of Health and Social CareStated planned
4. Action
  Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
5. Action
  Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
6. Action
  Implement NHS 111 First and pre-Emergency Department triage and streaming services across Greater Manchester localities.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
7. Action
  Launch a Greater Manchester campaign promoting NHS 111 First before emergency department attendance.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
8. Action
  Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
9. Action
  Review community-based capacity to support discharges.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
10. Action
  Review elective-care activity within hospitals to assess whether capacity can be provided for patients with urgent care needs.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Samuel Garner · 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

Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

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
Lack of appropriate Emergency Department space for treating vulnerable patients
Wider context from the report
“2. As a result of the lack of appropriate space Mr Garner for an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED. This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need. ”
Source location
Samuel Garner · Prevention of Future Deaths report
Page 2 · concerns
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 to maintain sufficient Emergency Department capacity during recurring periods of high demand
Wider context from the report
“1. The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department. This had been typical of the picture in both the preceding and following weeks due to winter pressures/demands. ”
Source location
Samuel Garner · Prevention of Future Deaths report
Page 2 · concerns
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
Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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 implementing Same Day Emergency Care to reduce non-elective hospital admissions.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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 additional funding to alleviate Covid-19 winter pressures and support NHS capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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
Maintain Nightingale Hospitals and their surge capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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
Maintain NHS use of independent-sector hospital capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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
Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.

Verbatim wording from the response
“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complexity care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
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 the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP also has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations, when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020
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
Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.

Verbatim wording from the response
“It should be noted that all of the acute trusts in Greater Manchester now utilise a patient safety checklist in their Emergency Departments. These checklists are time-based frameworks that outline clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to help mitigate some of the risks associated with corridor care. These have been adopted from the national checklist template which was published in 2017 and which has been proven to improve clinical processes and reduce harm and serious incidents from unrecognised patient deterioration.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020
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 NHS 111 First and pre-Emergency Department triage and streaming services across Greater Manchester localities.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently when we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 2 · response
Published 1 October 2020
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
Launch a Greater Manchester campaign promoting NHS 111 First before emergency department attendance.

Verbatim wording from the response
“I can confirm that all localities within GM have now gone live during the last 3 weeks with their services. A new national campaign to promote 111 First will be launched in early December which will encourage patients to call 111 before deciding to attend an emergency department.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020
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
Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020
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
Review community-based capacity to support discharges.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020
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
Review elective-care activity within hospitals to assess whether capacity can be provided for patients with urgent care needs.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020
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
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
13 Jul2020
Manchester South
Concerns raised1
1. Lack of sufficient emergency department and inpatient bed capacity
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.
  Stated by Department of Health and Social CareStated planned
1. Action
  Provide NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.
  Stated by Department of Health and Social CareStated planned
2. Action
  Provide £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.
  Stated by Department of Health and Social CareStated completed
3. Action
  Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.
  Stated by Department of Health and Social CareStated planned
4. Action
  Implement NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
5. Action
  Implement a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
6. Action
  Develop more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
7. Action
  Implement the Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
8. Action
  Create additional community-based capacity to support discharge pathways and improve acute-care patient flow.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

John Cheetham · 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

John Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

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
Lack of sufficient emergency department and inpatient bed capacity
Wider context from the report
“2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity. The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months. As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED. 3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity. The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed. ”
Source location
John Cheetham · Prevention of Future Deaths report
Page 2 · concerns
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
Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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
Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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
Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.

Verbatim wording from the response
“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complex care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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 NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.

Verbatim wording from the response
“NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £300million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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 £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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
Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.

Verbatim wording from the response
“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care homes so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 1 October 2020
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 NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 the Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.

Verbatim wording from the response
“Point 3 – hospital bed capacity and the discharge of patients”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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
Create additional community-based capacity to support discharge pathways and improve acute-care patient flow.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. As a result, there has been a significant reduction in the proportion of long stay patients and acute hospital bed occupancy levels across all Greater Manchester sites. This has helped to improve flow from Emergency Departments and therefore helped reduce crowding. Bed occupancy is currently on average 83% across Greater Manchester, which is at least 10% lower than the same period last year.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 3 · response
Published 1 October 2020
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
Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 1 · response
Published 1 October 2020
Open published response
27 Feb2020
Northamptonshire
Concerns raised1
1. Emergency department overcrowding
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide £145 million in capital funding for winter hospital improvements, including upgraded wards and redeveloped emergency departments.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Mr Mohan Acharya · 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

Mr Mohan Acharya died at Northampton General Hospital on 8 March 2018 from bronchopneumonia causing sepsis or infection, hypovolemia and cardiac arrest. The report raised concerns about emergency department crowding, which is associated with increased mortality among admitted patients and was reported to cause approximately 500 deaths per year.

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
Emergency department overcrowding
Wider context from the report
“According to the Royal College of Emergency Medicine:- 1. Emergency department crowding is associated with increased mortality amongst admitted patients; and 2. Approximately 500 deaths per year are caused by overcrowded Emergency Departments. ”
Source location
Mr Mohan Acharya · Prevention of Future Deaths report
Page 1 · concerns
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
Provide £145 million in capital funding for winter hospital improvements, including upgraded wards and redeveloped emergency departments.

Verbatim wording from the response
“Winter is a particularly demanding time for the NHS and therefore, in 2019, the Government provided £145 million in capital funding to help winter improvements in hospitals. This included upgraded wards and re-developed A&E departments that the NHS expected would bring the equivalent of an additional 900 beds.”

Source location
2020-0045-Response-from-the-Department-of-Health-and-Social-Care
Page 2 · response
Published 9 March 2020
Open published response
28 Apr2018
Blackpool and the Fylde
Concerns raised1
1. Insufficient staff capacity and time to assess and care for patients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Complete a capacity and demand review of Emergency Department nursing and medical staffing.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Prepare and submit a paper seeking approval for increased Emergency Department staffing establishment.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Continue substantive recruitment to staffing vacancies and provide safe day-to-day shift cover.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
1. Action
  Identify, escalate and safely manage medical and nursing staffing gaps through governance arrangements.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Operate the Better Care Now programme to improve patient flow across the health system.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Develop and implement an Escalation and Surge Protocol with agreed escalation criteria and assigned actions.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
4. Action
  Use the SAFER care bundle to improve ward patient management and discharge planning.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
5. Action
  Introduce a centralised control room to improve operational management of patient flow.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
6. Action
  Maximise Ambulatory Emergency Care pathways so suitable patients are managed outside the Emergency Department.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
7. Action
  Introduce therapies in the Emergency Department to accelerate admission or discharge decisions.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
8. Action
  Provide triage nurses at reception to improve streaming and fast initial assessment.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Existing recruitment, shift-by-shift staffing and governance arrangements are considered sufficient to identify, escalate and safely manage staffing gaps pending establishment approval.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Catherine Burns · 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

Catherine Burns was admitted to hospital with abdominal pain, deteriorated during a prolonged wait for medical assessment, suffered respiratory arrest, and died on 5 December 2017. The principal concerns were emergency department workload, delayed medical assessment, insufficient monitoring, and failure to recognise deterioration promptly, creating a risk of future deaths.

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 staff capacity and time to assess and care for patients
Wider context from the report
“I am concerned that staff were unable to provide the level of care to Catherine Burns that they would have liked to provide or which they felt was appropriate and that that this was due to the number of patients they were expected to care for. Consequently deterioration in her condition was not appreciated as quickly as it may otherwise have been. I am concerned that even during an extremely busy shift for a patient to be triaged as requiring assessment by a doctor and for that patient to then not be seen by a patient for over five hours risks future deaths and especially if the nursing staff are not able to monitor the patient as regularly as they may prefer. When giving consideration to writing a report to prevent future deaths Coroners are not limited to deaths which are felt to have been contributed to by the issue causing the Coroner some concern. As stated above the care afforded to Mrs Burns did not in my view alter the outcome for her but this should not prevent this report being written if I believe the duty upon me is met. I received impressive evidence from a Sister whose role was to co-ordinate the assessment area. She explained that during the entirety of the shift the staff had been dealing with approximately one third more patients than when they are performing at what is usually regarded as full capacity. However this was not an isolated incident and this had been the position throughout December, January, and February and that it has remained an issue which is persisting and cannot be solely attributed to what is sometimes described as “winter pressures”. It may well come as no surprise that the Emergency Department staff is facing these pressures and it may be that you feel that as a Trust you are doing all that you feel that you can to minimise the impact caused by the increased workload. Indeed I received helpful evidence during the inquest from the co-ordinator of the Emergency Department who explained that efforts have been made to review practices in order to make the system more efficient and hopefully be able to cope with over-capacity. Nevertheless, I believe that I have a duty to write this letter because I feel that there is a risk of future deaths caused or contributed to by staff not having the time to assess and care for patients due to their workload meaning any potentially significant deterioration in a patient’s condition may go unrecognised or is under-appreciated and with serious consequences. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”
Source location
Catherine Burns · Prevention of Future Deaths report
Page 3 · concerns
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
Complete a capacity and demand review of Emergency Department nursing and medical staffing.

Verbatim wording from the response
“In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
Prepare and submit a paper seeking approval for increased Emergency Department staffing establishment.

Verbatim wording from the response
“In response to the increase in demand on ED, the Emergency Department has undertaken a capacity and demand review of nursing and medical staffing and found that an increase in establishment is required. Accordingly, a paper has been prepared and submitted to the Executive Team for consideration.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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 substantive recruitment to staffing vacancies and provide safe day-to-day shift cover.

Verbatim wording from the response
“Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
Identify, escalate and safely manage medical and nursing staffing gaps through governance arrangements.

Verbatim wording from the response
“Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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 Better Care Now programme to improve patient flow across the health system.

Verbatim wording from the response
“The Better Care Now programme led by myself as Medical Director is in place to improve patient flow through the whole health system. As this programme begins to deliver, the pressure of overcrowding in the Emergency Department will begin to ease.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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 and implement an Escalation and Surge Protocol with agreed escalation criteria and assigned actions.

Verbatim wording from the response
“As part of that programme of work, the Department is developing an Escalation and Surge Protocol to help coordinate a consistent and effective response to an increase in demand. The criteria for escalation has been agreed and includes an escalation in the wait to be seen. Actions are being assigned to support the nurse and doctor in charge of the Emergency Department to manage the pressure effectively and gain the support required to de-escalate. Escalation is being assessed through two hourly Safety Huddles and six times daily at bed meetings.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
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
Use the SAFER care bundle to improve ward patient management and discharge planning.

Verbatim wording from the response
“Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Introduce a centralised control room to improve operational management of patient flow.

Verbatim wording from the response
“Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Maximise Ambulatory Emergency Care pathways so suitable patients are managed outside the Emergency Department.

Verbatim wording from the response
“Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Introduce therapies in the Emergency Department to accelerate admission or discharge decisions.

Verbatim wording from the response
“Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 2 · response
Published 1 July 2018
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 triage nurses at reception to improve streaming and fast initial assessment.

Verbatim wording from the response
“Increased demand in the Emergency Department is a reflection of the performance of the whole health system. As above, the Better Care Now programme is designed to introduce service developments in Primary, Community, and Secondary care to ensure patients receive treatment close to home as possible and at the right time. Working closely with the Emergency Care Improvement Programme and NHS Improvement, the Division is embedding a number of improvements which will have an impact on overcrowding in the Emergency Department:”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 2 · response
Published 1 July 2018
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
Existing recruitment, shift-by-shift staffing and governance arrangements are considered sufficient to identify, escalate and safely manage staffing gaps pending establishment approval.

Verbatim wording from the response
“Until such time as an increase in establishment has been agreed, the Department continues to recruit substantively to vacancies and cover staffing safely on a day to day, shift by shift basis. There are robust governance structures in place to ensure that both medical and nursing staffing gaps are identified early, escalated and managed safely.”

Source location
2018-0132-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
Page 1 · response
Published 1 July 2018
Open published response
17 May2017
North Wales (East and Central)
Concerns raised1
1. Failure to maintain adequate emergency department staffing
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Recruit and increase funded nursing and medical staffing at Ysbyty Glan Clwyd ED.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
2. Action
  Align senior medical staffing hours with peak ED demand.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
3. Action
  Recruit medical staff and revise staffing rotas at Ysbyty Maelor Wrexham ED.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
AI-generated summary

Lilly Baxandall · 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

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

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 adequate emergency department staffing
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Source location
Lilly Baxandall · Prevention of Future Deaths report
Page 1 · concerns
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
Recruit and increase funded nursing and medical staffing at Ysbyty Glan Clwyd ED.

Verbatim wording from the response
“• On-going recruitment of nursing and medical staff is a key focus. This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staff to all posts although recent recruitment campaigns for senior medical staff have met with success. It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
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
Align senior medical staffing hours with peak ED demand.

Verbatim wording from the response
“• The service is also working towards better matching senior medical staff working hours with times of peak patient demand. The aim is to have the Consultant late day shift extended from 18.00hrs to 22.00hrs and have a second Consultant working until 9pm Monday to Friday”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
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
Recruit medical staff and revise staffing rotas at Ysbyty Maelor Wrexham ED.

Verbatim wording from the response
“• The recruitment of medical staff is ongoing to improve cover of the medical rota from August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies currently covered with locum Consultants. There is a focused campaign of work ongoing to recruit to these key posts on a permanent basis.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of emergency department bed capacity

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised4

Lack of emergency department capacity for timely ambulance patient transfer

Failure to maintain emergency department and inpatient capacity for timely ambulance admissions

Limited capacity for diagnosis and treatment while patients wait in ambulances

Reliance on safety checks for patients left in ambulances because of emergency department space delays

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.18

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Insufficient senior emergency department doctor staffing at night

Concerns raised2

Lack of appropriate Emergency Department space for treating vulnerable patients

Failure to maintain sufficient Emergency Department capacity during recurring periods of high demand

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.13

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 18

Respondent positions 3

Actions described in response 13

Respondent positions 1