Recurring concern

Insufficient emergency-department capacity for timely patient care

Get email alerts

Request correction

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.

19 Feb2025
Staffordshire and Stoke-on-Trent
Concerns raised1
1. Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area
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 1
1. Action
  Reinstate a named-nurse model in the resuscitation area and audit it through internal and ICB review processes.
  Stated by University Hospitals of North Midlands NHS TrustStated planned
Respondent positions 4
1. Position
  Flexible nursing allocation is preferred to fixed one-to-one resuscitation staffing because it prioritises staff according to acuity, surge and skill.
  Stated by University Hospitals of North Midlands NHS TrustExisting arrangements considered sufficient
1. Position
  A team approach, supported by flexible staffing and specialist support, is considered more effective than assigning a Named Nurse in the resuscitation area.
  Stated by NHS EnglandExisting arrangements considered sufficient
2. Position
  The Trust does not consider that insufficient nursing staff caused the failure to recognise Philip’s deterioration.
  Stated by NHS EnglandDisputes the concern
3. Position
  The Trust is responsible for providing further comments and information on actions taken since the inquest concerning the Coroner’s concerns.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Philip John UNWIN · 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

Philip John Unwin, aged 68, was admitted to hospital with fever, shortness of breath and chest pain, and was later confirmed to have sepsis secondary to pneumonia. His condition deteriorated while he remained in the Emergency Department resuscitation area, and he died in hospital on 3 April 2024 from multi-organ failure secondary to pneumonia. Concerns included delayed medical review and escalation to intensive care, staffing in the resuscitation area not complying with national guidance, and recommendations from an internal investigation not having been acted upon in this respect.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area
Wider context from the report
“Although the conclusion of the inquest was one of Natural Causes there was evidence of a failure for medical teams to respond to concerns that the patient was deteriorating whilst awaiting assessment in the resuscitation area of the Emergency Department of Royal Stoke University Hospital. It was accepted by witnesses from the hospital that the patient should not have deteriorated to a 'moribund' state within that area of the hospital when concerns had been raised by staff and family, and that review and escalation to intensive care should have been initiated sooner (albeit the evidence was that this did not more than minimally contribute to the death). As a result of the concerns raise by hospital staff regarding missed opportunities to escalate care in a timely manner the hospital undertook a Patient Safety Incident Investigation (PSII). As a result of that investigations a number of recommendations were made with assurances given to the report author that work is being undertaken to review and amend policies and procedures focused on reviewing, escalating and referring deteriorating patients. However, the inquest was told that although the Emergency Department Resuscitation area was where the illest patients were placed awaiting review, staffing levels were not in compliance with national guidance. The Royal College of Emergency Medicine (RCEM) “Nursing Workforce Standards for Type 1 Emergency Departments” (Appendix 5) states “There will be a minimum of Registered Nurse to each patient in the resuscitation area”. The recommendation continued that there should be a named nurse allocated to each patient which should be 1:1 as per National Guidance. The concern is that the current model of staffing within the Emergency Department Resus area is not in compliance with national guidance and the recommendations following internal investigation into the care afforded to the deceased have not been acted upon in this respect. ”
Source location
Philip John UNWIN · 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
Reinstate a named-nurse model in the resuscitation area and audit it through internal and ICB review processes.

Verbatim wording from the response
“We previously trialled a ‘named nurse’ approach within resus and the team felt this lacked flexibility as they used an ‘allocated nurse’ based on patient need and skill-set per shift but, following further review, we have decided to structure this and reinstate this model to include a ‘named nurse’ within our resus from early April 2025. The named nurse model will then be audited/monitored via our internal review processes and as part of the Integrated Care Board (ICB) reviews of our Emergency Department.”

Source location
Response from Royal Stoke University Hospital
Page 3 · response
Published 21 February 2025
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
Flexible nursing allocation is preferred to fixed one-to-one resuscitation staffing because it prioritises staff according to acuity, surge and skill.

Verbatim wording from the response
“Royal Stoke Hospital has a Type 1 Emergency Department and has a total of 8 cubicles in the resuscitation (resus) area, however the team try to keep resus at a maximum of 6 patients leaving 1 space for paediatric emergencies (and when in use paediatric nursing staff from Children’s Emergency Department attend), and 1 cubicle space for any trauma patients. There are always 4 Nurses who are allocated to the department for each shift in resus and then the department flexes our nurses to cover all Emergency Department Areas, flexing into the area with the most need at the time.”

Source location
Response from Royal Stoke University Hospital
Page 2 · response
Published 21 February 2025
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
A team approach, supported by flexible staffing and specialist support, is considered more effective than assigning a Named Nurse in the resuscitation area.

Verbatim wording from the response
“UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
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 Trust does not consider that insufficient nursing staff caused the failure to recognise Philip’s deterioration.

Verbatim wording from the response
“UHNM advise that having a Named Nurse in the ED has been tried previously at the Royal Stoke University Hospital, but a ‘team approach’ has been found to work better in the Resuscitation area of the ED rather than care falling to one medical professional. Trauma patients are always nursed 1:1 and this is due to the professional judgement required and the ability to flex staff around the department and into resuscitation with the support of an Operating Department Practitioner (ODP), the (supernumerary) Nurse in Charge and any outreach support for trauma calls. UHNM have asked us to note that the PSII identified that there was clear escalation by relevant nursing staff, and that it is not their belief that a lack of nursing staff led to the failure to recognise Philip’s deterioration.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
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 Trust is responsible for providing further comments and information on actions taken since the inquest concerning the Coroner’s concerns.

Verbatim wording from the response
“It is appropriate that UHNM provide any further comment regarding the Coroner’s concerns. It is NHS England’s understanding that they will be providing further information on actions taken by the Trust since the inquest into Philip’s death in their response to the Coroner.”

Source location
Response from NHS England
Page 2 · response
Published 21 February 2025
Open published response
4 Feb2025
North East Kent
Concerns raised1
1. Unavailability of beds for emergency department patients
This report raised 4 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 10
1. Action
  Increase same-day emergency care so more patients are seen, treated and discharged within one day.
  Stated by Department of Health and Social CareStated planned
2. Action
  Increase the proportion of patients discharged by or on day seven of admission.
  Stated by Department of Health and Social CareStated planned
3. Action
  Develop local NHS and social-care partnerships to reduce delayed discharges and patients waiting to leave hospital.
  Stated by Department of Health and Social CareStated planned
1. Action
  Reform the Better Care Fund so pooled NHS and local-authority funding supports reducing emergency admissions, delayed discharges and care-home admissions.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Continue operating-model work with regions to support providers in reducing Emergency Department crowding.
  Stated by NHS EnglandStated in progress
3. Action
  Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.
  Stated by NHS EnglandStated completed
4. Action
  Strengthen use of Discharge Ready Date and Reason for Discharge Delay data to identify and reduce discharge delays.
  Stated by NHS EnglandStated in progress
5. Action
  Work with local areas and health, social care and local-government partners to maximise discharge-funding impact and improve timely patient discharge.
  Stated by NHS EnglandStated in progress
6. Action
  Collect daily data on patients experiencing long Emergency Department waits and track actions to support appropriate accommodation and patient-safety review.
  Stated by NHS EnglandStated in progress
7. Action
  Collect weekly data on patients waiting over 100 days for discharge and use system leadership, coordination calls and regional engagement to enable appropriate discharge.
  Stated by NHS EnglandStated in progress
AI-generated summary

Dorothy Lilian REID · 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

Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.

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
Unavailability of beds for emergency department patients
Wider context from the report
“(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death. ”
Source location
Dorothy Lilian REID · 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
Increase same-day emergency care so more patients are seen, treated and discharged within one day.

Verbatim wording from the response
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
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
Increase the proportion of patients discharged by or on day seven of admission.

Verbatim wording from the response
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
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 local NHS and social-care partnerships to reduce delayed discharges and patients waiting to leave hospital.

Verbatim wording from the response
“Regarding the concern raised about bed capacity and delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
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
Reform the Better Care Fund so pooled NHS and local-authority funding supports reducing emergency admissions, delayed discharges and care-home admissions.

Verbatim wording from the response
“We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
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 operating-model work with regions to support providers in reducing Emergency Department crowding.

Verbatim wording from the response
“NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 1 · response
Published 7 February 2025
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
Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.

Verbatim wording from the response
“NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 1 · response
Published 7 February 2025
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
Strengthen use of Discharge Ready Date and Reason for Discharge Delay data to identify and reduce discharge delays.

Verbatim wording from the response
“NHS England recognises the significant impact that delayed discharges have on hospital flow, ambulance handovers and the patients affected by these delays. To address this, we are strengthening the use of Discharge Ready Date (DRD) and Reason for Discharge Delay (RfDD) data to gain a clearer understanding of discharge delays and their key contributing factors, both locally and nationally, so that measures can be taken to reduce the number of patients occupying beds who are ready for discharge.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with local areas and health, social care and local-government partners to maximise discharge-funding impact and improve timely patient discharge.

Verbatim wording from the response
“Over the coming year we will be working with local areas to support them to maximise the impact of this investment, for example by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including the Local Government Association (LGA), Directors of Social Services (DASSs) and Care and Health Improvement Advisers (CHIAs) to support local systems to improve timely discharge of patients.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Collect daily data on patients experiencing long Emergency Department waits and track actions to support appropriate accommodation and patient-safety review.

Verbatim wording from the response
“NHS England has commenced a data collection of patients experiencing long waits in Emergency Departments on a daily basis and will ensure actions are in place to appropriately accommodate these patients as soon as possible. The data is discussed at the National Coordination Centre call, with actions tracked to ensure executive oversight and assurance as well as patient safety and harm reviews of/for patients waiting.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Collect weekly data on patients waiting over 100 days for discharge and use system leadership, coordination calls and regional engagement to enable appropriate discharge.

Verbatim wording from the response
“In addition, to reduce the number of very long discharge waits, we have been collecting weekly data to identify the number of patients waiting over 100 days and will ensure actions are being taken through system leadership to enable patients to be discharged to the most appropriate setting as soon as possible. The patients identified as waiting over 100 days will be discussed at a weekly National Coordination Centre call, and themes will be tracked through weekly regional engagement meetings.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
17 Jan2025
South Wales Central
Concerns raised1
1. Failure to provide emergency department care in appropriate clinical spaces
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 5
1. Action
  Develop a capital programme for a dedicated ambulatory bay, including feasibility, costing and timeframe work.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
2. Action
  Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
3. Action
  Strengthen float-nurse monitoring, senior review, safety huddles and escalation processes for patients receiving care in non-clinical spaces.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
1. Action
  Maintain a ring-fenced emergency-department escalation space and activate site-wide responses when its capacity is exceeded.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
2. Action
  Operate a dedicated BRATZ assessment area to support rapid triage and safe, efficient ambulance handovers.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
AI-generated summary

Jackson Yeow · 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

Jackson Yeow, aged 16, became seriously unwell with abdominal pain and vomiting and later developed diabetic ketoacidosis and other complications. He waited approximately 9½ hours for an ambulance after his family called 999, and died on 9 April 2022. Concerns included delays in ambulance handovers associated with emergency department overcrowding, corridor care, and delayed discharge of medically fit patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide emergency department care in appropriate clinical spaces
Wider context from the report
“Although the Cwm Taf Morgannwg University Health Board did not provide direct care to Jackson Yeow during the period within scope, it provided the evidence of a consultant in emergency medicine to the inquest on the issue of delays in ambulance handovers at the Princess of Wales Hospital, Bridgend. That evidence directly identified the following matters of concern: (1) Care for patients in the emergency department is frequently provided in the corridor and other non clinical spaces, which: (a) Impedes efficient clinical assessment, causing clinicians to take longer performing tasks and rendering clinical care more difficult; (b) Impedes the ability of staff to recognize a patient’s deteriorating condition; (c) Increases patient morbidity through environmental factors compromising a patient’s ability to sleep, hygiene and nutrition. (d) May slow the process of ambulance handovers. (2) Care in corridors and other non clinical spaces has been normalized, which in the opinion of the consultant who gave evidence is unsafe. (3) When conducted routinely, care in corridors and other non clinical spaces reduces the capacity of the Emergency Department so that should acuity escalate, it is likely to cause delays to the release of ambulances. (4) The underlying obstacle to improving flow through the hospital and relieving pressure on the Emergency Department is the significant number of patients who are medically fit to be discharged but whose discharge is delayed due to non medical reasons. ”
Source location
Jackson Yeow · 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
Develop a capital programme for a dedicated ambulatory bay, including feasibility, costing and timeframe work.

Verbatim wording from the response
“We are committed to ongoing improvement across our Emergency Departments and working towards the eradication of corridor care unless in extremis. As part of this work the leadership team are working in collaboration with the POW site based team to develop a capital programme to create a dedicated ambulatory bay. The scoping for this work has already happened and capital colleagues are working through feasibility, costing and timeframes for this work. This is a priority to reduce the reliance on non-clinical spaces and to improve patient experience within the ED.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 20 January 2025
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
Roll out the Optimise patient-flow programme to the Princess of Wales site using real-time tracking, eWhiteboards, Red2Green and SAFER board rounds.

Verbatim wording from the response
“Additionally, the STAMP (Strategic Transformation of Acute Medicine Programme) and OPTIMISE programmes have been introduced to improve patient flow across CTM. The Optimise programme utilises real-time digital tools, such as Red2Green and eWhiteboards, to ensure patients are placed in the right clinical area as quickly as possible. Early implementation of these initiatives across Royal Glamorgan and Prince Charles Hospital have significantly reduced patient delays and improved overall care efficiency and the next phase of roll out includes POW site.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 20 January 2025
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
Strengthen float-nurse monitoring, senior review, safety huddles and escalation processes for patients receiving care in non-clinical spaces.

Verbatim wording from the response
“CTMUHB recognises that corridor care presents significant challenges to efficient clinical assessment and patient safety. We are actively working to reduce reliance on non-clinical spaces through investment in additional nursing staff, transformation programmes and improvements in patient flow, and the implementation of enhanced escalation processes.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 1 · response
Published 20 January 2025
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 a ring-fenced emergency-department escalation space and activate site-wide responses when its capacity is exceeded.

Verbatim wording from the response
“The float nurse role has been strengthened to provide continuous monitoring of patients in non-clinical spaces. Additionally, DATIX incident reporting is used to capture any patient safety concerns, ensuring rapid escalation to the appropriate senior staff for immediate action. Any patient safety concerns are escalated immediately with prompt transfer of patients to a more clinically appropriate area. This is supported by a ring-fenced escalation space within the ED at POW. Once this space is breached initiates a site based response to on-board patients into pre-identified areas across the site in order to balance risk.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 5 · response
Published 20 January 2025
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 a dedicated BRATZ assessment area to support rapid triage and safe, efficient ambulance handovers.

Verbatim wording from the response
“Corridor care can contribute to delays in ambulance handovers. To mitigate this, we have implemented: - A fully recruited nursing workforce, reducing the reliance on agency staff and ensuring a consistent, well-trained team is available to manage ambulance arrivals efficiently and make dynamic risk-based decisions on ensuring timely handover of patients and release of ambulance resources. - We have made significant improvements at POW on ambulance handover times over the past 18 months and we are committed to ongoing improvement in this area. - A dedicated BRATZ assessment area, where patients are triaged quickly to allow for safe and efficient handovers.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 5 · response
Published 20 January 2025
Open published response
15 Oct2024
West Sussex, Brighton and Hove
Concerns raised1
1. Failure to provide sufficient designated clinical space for Emergency Department 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 9
1. Action
  Publish principles for providing safe, good-quality care in temporary escalation spaces when demand exceeds capacity.
  Stated by NHS EnglandStated completed
2. Action
  Develop the NHS England operating model to help regional teams support providers to eliminate Emergency Department crowding.
  Stated by NHS EnglandStated in progress
3. Action
  Continue developing services that shift unplanned urgent activity outside acute hospitals, including proactive care, admission alternatives and improved discharge.
  Stated by NHS EnglandStated in progress
1. Action
  Conduct joint regional visits and focused reviews of non-designated Emergency Department care, engaging staff, patients and relatives and providing improvement feedback.
  Stated by NHS EnglandStated completed
2. Action
  Use operational planning guidance to direct systems toward improved patient flow, productivity, length of stay and clinical outcomes.
  Stated by NHS EnglandStated completed
3. Action
  Advance the Unscheduled Care Navigation Hub to reduce avoidable emergency-department attendance and support alternative admission pathways.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
4. Action
  Implement continuous flow with scheduled transfers from the Acute Assessment Unit to specialty medicine and frailty wards.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
5. Action
  Open the Surgical Assessment Unit to receive surgical presentations and ambulances.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
6. Action
  Expand the Surgical Assessment Unit by adding trolley beds and patient chairs as nursing recruitment allows.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  NHS England is best placed to address local urgent and emergency care performance and RSCH’s mitigation of temporary escalation space use.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Tamara DAVIS · 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

Tamara Davis attended hospital after being unwell for five days and was treated for suspected chest infection before deteriorating and dying on 13 December 2022 from multi-organ failure associated with bronchopneumonia caused by Influenza A infection. A substantive concern was the use of an overcrowded Emergency Department corridor for patient care, where patients lacked privacy, toilet facilities and confidentiality, and where the area was not designated as a clinical area or included in the nursing staffing template.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide sufficient designated clinical space for Emergency Department patients
Wider context from the report
“During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area and is not included within the Nursing staffing template for the ED. When Ms Davis was treated in the Royal Sussex County Hospital, Brighton on 11 December 2022 there were, at times, more than 20 patients in that area. Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who are sent to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. There was no evidence as to when, and if, this practice would no longer be necessary. I heard that the provision of care in the ED corridor meant that patients lacked privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity. I heard that in the event of a major incident University Hospitals Sussex NHS Foundation Trust would have to clear the Emergency Department, as they had done on occasion, as this would be the only way to create the necessary clinical space when the department was already over capacity and using the corridor. I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to move patients to. ”
Source location
Tamara DAVIS · 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
Publish principles for providing safe, good-quality care in temporary escalation spaces when demand exceeds capacity.

Verbatim wording from the response
“The delivery of care in temporary escalation spaces (TES) in departments experiencing patient crowding (including beds and chairs) is not acceptable and should not be considered as standard across the NHS. TES refers to care given in any unplanned settings (such as corridors) and recently NHS England have published a set of principles for supporting improved quality of care should patient demand outstrip capacity - NHS England – Principles for providing safe and good quality care in temporary escalation spaces (16 September 2024). These principles have been developed to support point-of-care staff to provide the safest, most effective and”

Source location
Response from NHS England
Page 1 · response
Published 15 October 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop the NHS England operating model to help regional teams support providers to eliminate Emergency Department crowding.

Verbatim wording from the response
“In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.”

Source location
Response from NHS England
Page 2 · response
Published 15 October 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue developing services that shift unplanned urgent activity outside acute hospitals, including proactive care, admission alternatives and improved discharge.

Verbatim wording from the response
“In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.”

Source location
Response from NHS England
Page 2 · response
Published 15 October 2024
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
Conduct joint regional visits and focused reviews of non-designated Emergency Department care, engaging staff, patients and relatives and providing improvement feedback.

Verbatim wording from the response
“My Regional colleagues in the South East Clinical Quality Improvement team have recently visited the Emergency Departments at both University Hospitals Sussex in Worthing and Royal Sussex County Hospital as part of a programme of joint Nursing and Integrated Care Board (ICB) visits to NHS Trusts, led by their Deputy Director. The programme of visits aims to understand how and why patients are selected to reside in non-designated areas, how they are observed for deterioration, and how dignified care can be provided. These focused reviews of non-designated care practices in the Emergency Department have included engaging with staff, patients and relatives to test safety measures in place and provide detailed feedback for the organisations on areas for improvement.”

Source location
Response from NHS England
Page 2 · response
Published 15 October 2024
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 operational planning guidance to direct systems toward improved patient flow, productivity, length of stay and clinical outcomes.

Verbatim wording from the response
“In the meantime, NHS England is working through the operating model so that NHS England’s Regions can support providers to eliminate crowding in Emergency Departments in the longer term. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow, and this has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we are continuing to develop services that shift activity from acute hospital settings to settings outside an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.”

Source location
Response from NHS England
Page 2 · response
Published 15 October 2024
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
Advance the Unscheduled Care Navigation Hub to reduce avoidable emergency-department attendance and support alternative admission pathways.

Verbatim wording from the response
“The Medicine Division have employed an Operational Flow Improvement Manager who is leading the Hospital Alternative Oversight Programme. The aim of this work is to reduce admissions, optimise flow through the hospital, and smooth discharge pathways and processes. A number of the initiatives already in progress are as follows:”

Source location
Response from University Hospitals Sussex
Page 1 · response
Published 15 October 2024
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 continuous flow with scheduled transfers from the Acute Assessment Unit to specialty medicine and frailty wards.

Verbatim wording from the response
“Continuous Flow Model - Reducing overcrowding in the Emergency Department”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 15 October 2024
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
Open the Surgical Assessment Unit to receive surgical presentations and ambulances.

Verbatim wording from the response
“Surgical Assessment Unit (SAU)”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 15 October 2024
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 the Surgical Assessment Unit by adding trolley beds and patient chairs as nursing recruitment allows.

Verbatim wording from the response
“The SAU opened in October 2024 and is being expanded in line with nursing recruitment. This will increase the hospital’s bed stock by 12 patient trolley beds and 12 patient chairs. It is expected to manage most surgical patient presentations to the ED and receive ambulances directly.”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 15 October 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is best placed to address local urgent and emergency care performance and RSCH’s mitigation of temporary escalation space use.

Verbatim wording from the response
“The report raises concerns over emergency department capacity, poor patient flow and the use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand that your report and matters of concerns have also been sent to NHS England, and they are best placed to respond with the specific actions being taken locally to improve urgent and emergency care performance at RSCH.”

Source location
Response from DHSC
Page 1 · response
Published 15 October 2024
Open published response
18 Dec2023
North Wales (East and Central)
Concerns raised2
1. Insufficient Emergency Department space for patient demand
2. Insufficient doctors and nurses for Emergency Department patient demand
This report raised 10 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 9
1. Action
  Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
  Stated by Welsh GovernmentStated completed
2. Action
  Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
  Stated by Welsh GovernmentStated completed
3. Action
  Provide £50 million in additional funding to support urgent and emergency care improvement.
  Stated by Welsh GovernmentStated completed
1. Action
  Fund expanded same-day emergency care capacity across north Wales district general hospitals.
  Stated by Welsh GovernmentStated completed
2. Action
  Provide over £500,000 to improve Betsi Cadwaladr emergency-department facilities and waiting-room experiences.
  Stated by Welsh GovernmentStated completed
3. Action
  Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
  Stated by Betsi Cadwaladr University LHBStated in progress
4. Action
  Continue expanding consultant staffing in the Emergency Department, now providing 8.6 whole-time-equivalent consultants plus one locum.
  Stated by Betsi Cadwaladr University LHBStated completed
5. Action
  Map the Emergency Department resource required to meet demand and national recommendations.
  Stated by Betsi Cadwaladr University LHBStated in progress
6. Action
  Review and increase the Emergency Department nurse staffing roster template through the annual staffing review.
  Stated by Betsi Cadwaladr University LHBStated in progress
AI-generated summary

Vivienne Greener · 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

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

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 Emergency Department space for patient demand
Wider context from the report
“2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department; ”
Source location
Vivienne Greener · Prevention of Future Deaths report
Page 4 · 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
Insufficient doctors and nurses for Emergency Department patient demand
Wider context from the report
“2. There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department; ”
Source location
Vivienne Greener · Prevention of Future Deaths report
Page 4 · 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
Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.

Verbatim wording from the response
“To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations of health boards and NHS trusts through an annual NHS planning framework. Organisations are expected to produce integrated medium-term plans annually, that respond to the priorities set in the NHS planning framework. The planning framework clearly sets out my expectation that health boards prioritise plans to improve timeliness of ambulance patient handovers to free up ambulance clinicians to respond to patients in the community. Given the relationship between both timely patient discharge and ambulance patient handover, I have also set a priority for improvement in patient flow.”

Source location
Response from Welsh Government
Page 2 · response
Published 28 December 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 a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.

Verbatim wording from the response
“To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:”

Source location
Response from Welsh Government
Page 2 · response
Published 28 December 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 £50 million in additional funding to support urgent and emergency care improvement.

Verbatim wording from the response
“To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:”

Source location
Response from Welsh Government
Page 2 · response
Published 28 December 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 expanded same-day emergency care capacity across north Wales district general hospitals.

Verbatim wording from the response
“• We have funded extensions in capacity for same day emergency care services which are treating and discharging hundreds of patients per month across the three district general hospitals in north Wales, freeing up precious bed capacity;”

Source location
Response from Welsh Government
Page 2 · response
Published 28 December 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 over £500,000 to improve Betsi Cadwaladr emergency-department facilities and waiting-room experiences.

Verbatim wording from the response
“Turning to strategic plans to support improvement in quality of care in emergency departments. I continue to support improvements in emergency departments through a range of measures and this year will publish a Quality Statement for care within the emergency departments, setting out my expectations for the service. To deliver this, we are bringing the voices of our clinical leaders together through the newly established Strategic Network for Critical Care, Trauma and Emergency Medicine and focusing on what matters most to people who use the service. I made over £500,000 of additional funding available to Betsi Cadwaladr University Health Board in December 2023 to support upgrades and improvements in their emergency departments which will enhance both patient and staff experiences in waiting rooms.”

Source location
Response from Welsh Government
Page 3 · response
Published 28 December 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
Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.

Verbatim wording from the response
“Processes are taking place in respect of patient flow to release capacity, however, we are reviewing the opportunity to create additional capacity in terms of infrastructure changes and a review of our current START clinical area. This would create a dedicated speciality waiting area with cubicles for review. This scoping is work in progress, and will be formalised.”

Source location
Response from Betso Cadwaladr University Health Board
Page 5 · response
Published 28 December 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
Continue expanding consultant staffing in the Emergency Department, now providing 8.6 whole-time-equivalent consultants plus one locum.

Verbatim wording from the response
“The Emergency Department at YGC is fully staffed with junior doctors, in line with the budgeted provision, and appropriate staffing levels are put in place through rota management each month, with mitigation in place for management of sickness and unplanned absence. In addition, staffing levels have been mitigated with the expansion of Consultant numbers since Mrs Greener’s death, and there are now 8.6 whole time equivalent Consultants plus 1 whole time equivalent locum. Our senior consultants, are also available 24/7 to attend to and support such cases as this, and all core clinical consultant shifts are covered.”

Source location
Response from Betso Cadwaladr University Health Board
Page 2 · response
Published 28 December 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
Map the Emergency Department resource required to meet demand and national recommendations.

Verbatim wording from the response
“The Emergency Department are continuously reviewing staffing in relation to increasing the core numbers to meet national recommendations within the funding envelope available, and work is ongoing to map the resource required to meet demands.”

Source location
Response from Betso Cadwaladr University Health Board
Page 3 · response
Published 28 December 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
Review and increase the Emergency Department nurse staffing roster template through the annual staffing review.

Verbatim wording from the response
“The YGC ED department along with the other two sites are in the process of being reviewed as part of the 2023/2024 annual nurse staffing review cycle and have they have proposed that the current staffing roster template is increased.”

Source location
Response from Betso Cadwaladr University Health Board
Page 4 · response
Published 28 December 2023
Open published response
20 Jul2023
Manchester South
Concerns raised1
1. Failure of Emergency Department capacity to provide timely clinical assessment
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 5
1. Action
  Improve patient flow through hospitals to reduce emergency department delays.
  Stated by NHS EnglandStated in progress
2. Action
  Speed up hospital discharges to reduce length of stay and improve flow.
  Stated by NHS EnglandStated in progress
3. Action
  Address unwarranted performance variation in the most challenged local systems.
  Stated by NHS EnglandStated in progress
1. Action
  Implement the Long Term Workforce Plan to improve training, staff retention, workforce reform and sustainable staffing.
  Stated by NHS EnglandStated planned
2. Action
  Publish national winter operational-resilience guidance addressing emergency department waits, crowding, flow and hospital length of stay.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  NHS Trusts are responsible for ensuring appropriate staffing, senior clinical support and diagnostic provision for anticipated demand.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Marianne Erika Oldham · 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

Marianne Erika Oldham was admitted to Tameside General Hospital with vomiting and abdominal pain and was diagnosed with a perforated sigmoid colon after a prolonged delay in clinical assessment and imaging. She deteriorated, was treated conservatively, and died from peritonitis. The report identified concerns about delays linked to Emergency Department demand, staffing shortages, and shortages of radiographers and radiologists.

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 of Emergency Department capacity to provide timely clinical assessment
Wider context from the report
“The inquest heard evidence that the very significant delay for Mrs Oldham to be seen by a clinician was due to the demand on Emergency Department Services. The inquest was told that delays of this length (9 hours) for patients who had been triaged to be seen within 60 minutes were not uncommon throughout the winter period across Greater Manchester and more widely. The demand was due to the volume of patients and the number of staff available to see and treat them. The delay was compounded by the shortage of radiographers and radiologists nationally meaning that even when a decision is taken for a scan it can take some time (9 an hour in this case) for it to take place and then reported on. In the time that Mrs Oldham was waiting to be seen she deteriorated very significantly meaning that by the time it was understood what the issue was she was very unwell and did not respond to conservative treatment which was all she was well enough for by that point. ”
Source location
Marianne Erika Oldham · 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
Improve patient flow through hospitals to reduce emergency department delays.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 28 July 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
Speed up hospital discharges to reduce length of stay and improve flow.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 28 July 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
Address unwarranted performance variation in the most challenged local systems.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care (UEC) services, including improving ambulance response times, increasing ambulance capacity through the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 28 July 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 Long Term Workforce Plan to improve training, staff retention, workforce reform and sustainable staffing.

Verbatim wording from the response
“Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”

Source location
Response from NHS England
Page 2 · response
Published 28 July 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
Publish national winter operational-resilience guidance addressing emergency department waits, crowding, flow and hospital length of stay.

Verbatim wording from the response
“In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks titled Delivering operational resilience across the NHS this winter. This includes focusing on reducing waiting times for patients and crowding in A&E departments, improving flow, and reducing length of stay in hospital settings.”

Source location
Response from NHS England
Page 1 · response
Published 28 July 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
NHS Trusts are responsible for ensuring appropriate staffing, senior clinical support and diagnostic provision for anticipated demand.

Verbatim wording from the response
“Nationally, there are clear requirements placed on NHS Trusts to ensure that the right skill mix of medics and other professional groups are in place to respond to the anticipated demand throughout a day. This includes the expectation that senior decision makers are available to support more junior doctors and that diagnostics can occur in line with best practice and clinical standards set by the National Institute for Clinical Excellence (NICE) and other bodies such as Royal Colleges and Faculties. It is, however, acknowledged that resourcing remains an issue across the NHS, with local services reporting over 112,000 vacancies. In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”

Source location
Response from NHS England
Page 2 · response
Published 28 July 2023
Open published response
19 Jul2023
Manchester South
Concerns raised1
1. Delays in transfer from ambulance to the Emergency Department
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 3
1. Action
  Improve patient flow through hospitals.
  Stated by NHS EnglandStated in progress
2. Action
  Speed up hospital discharges.
  Stated by NHS EnglandStated in progress
3. Action
  Focus NHS organisations on improving accident-and-emergency and ambulance handover times.
  Stated by NHS EnglandStated in progress
AI-generated summary

Evelyn Mary Dutton · 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

Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.

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
Delays in transfer from ambulance to the Emergency Department
Wider context from the report
“1. The inquest heard evidence that after her fall, on 28th June 2022, despite her age and frailty there was a prolonged wait for an ambulance to take her to hospital. This was due to the demands on the ambulance service that day. Once they reached hospital Mrs Dutton had to remain in the ambulance until a space became available for her in the Emergency Department. This was due to the pressure on the Emergency Department and was replicated across Greater Manchester. Once in the Emergency Department she then remained there until transfer to a ward on 29th June when a bed became available; 2. The evidence was that long waits for transfer to hospital and delays in being transferred to wards presented a significant risk to the health and wellbeing of elderly frail patients with hip fractures such as Mrs Dutton. The inquest was told that these delays were not unusual in summer of 2022. ”
Source location
Evelyn Mary Dutton · 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
Improve patient flow through hospitals.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 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
Speed up hospital discharges.

Verbatim wording from the response
“The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times, increasing ambulance capacity through growing the workforce, improving flow through hospitals, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 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
Focus NHS organisations on improving accident-and-emergency and ambulance handover times.

Verbatim wording from the response
“In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks titled Delivering operational resilience across the NHS this winter. This also included focusing on improvements around Accident & Emergency handover and ambulance handover times.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 2023
Open published response
19 Jul2023
Manchester South
Concerns raised1
1. Insufficient Emergency Department capacity causing prolonged patient delays
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 2
1. Action
  Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.
  Stated by Department of Health and Social CareStated completed
2. Action
  Put Same Day Emergency Care services in place across every hospital with a major emergency department.
  Stated by Department of Health and Social CareStated planned
AI-generated summary

Thelma Mary Radmore · 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

Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.

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 Emergency Department capacity causing prolonged patient delays
Wider context from the report
“1. The inquest heard that the long wait for an ambulance and prolonged delay in the Emergency Department were due to demand on services and resources available. The inquest heard evidence that the ambulance service challenges were exacerbated by waits outside Emergency Departments for space to become available for patients; 2. The wait Mrs Radmore experienced with the ambulance crew in the corridor was due to demand for space within the Emergency Department due to patient numbers and issues with patient flow due to challenges in discharging patients from wards; 3. In Mrs Radmore’s case the long delays meant that steps to reduce the risk from pressure ulcers such as a suitable mattress could not be taken at an early stage; 4. The inquest was told the situation had been ongoing throughout the preceding days and such delays were not unusual across the North West and nationally. ”
Source location
Thelma Mary Radmore · 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
Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift through 2024/25.

Verbatim wording from the response
“A key part of the plan has been to increase hospital capacity to improve patient flow. This will help reduce overcrowding in A&E, speeding up the handover of ambulance patients so ambulances can swiftly get back on the roads. To help deliver these improvements, we achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 21 July 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
Put Same Day Emergency Care services in place across every hospital with a major emergency department.

Verbatim wording from the response
“Same Day Emergency Care (SDEC) services will also 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 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 21 July 2023
Open published response
18 Jan2023
Norfolk
Concerns raised1
1. Failure to maintain Emergency Department capacity for safe ambulance-to-hospital transfer
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 5
1. Action
  Deliver the plan’s measures to improve urgent-care waiting times and ambulance response times.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Deliver 5,000 additional staffed, permanent hospital beds compared with 2022–23 plans.
  Stated by Department of Health and Social CareStated completed
3. Action
  Maintain the additional staffed hospital-bed capacity through 2024–25.
  Stated by Department of Health and Social CareStated planned
1. Action
  Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Ensure every acute hospital has access to a care transfer hub for complex discharges.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Lyn Mary BRIND · 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

Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain Emergency Department capacity for safe ambulance-to-hospital transfer
Wider context from the report
“6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. 7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. 8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. 7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community ”
Source location
Lyn Mary BRIND · 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
Deliver the plan’s measures to improve urgent-care waiting times and ambulance response times.

Verbatim wording from the response
“I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. The plan also commits to reducing average Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 24 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 5,000 additional staffed, permanent hospital beds compared with 2022–23 plans.

Verbatim wording from the response
“and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 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
Maintain the additional staffed hospital-bed capacity through 2024–25.

Verbatim wording from the response
“and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 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
Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.

Verbatim wording from the response
“We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 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
Ensure every acute hospital has access to a care transfer hub for complex discharges.

Verbatim wording from the response
“We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 24 January 2023
Open published response
4 Nov2022
Manchester South
Concerns raised1
1. Insufficient emergency department capacity causing delays in triage, assessment and treatment
This report raised 4 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
  Publish a two-year delivery plan to recover urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Deliver 5,000 additional staffed, permanent hospital beds to improve patient flow and reduce emergency-department overcrowding.
  Stated by Department of Health and Social CareStated completed
3. Action
  Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from emergency departments.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Philip Geoffrey Day · 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

Philip Geoffrey Day was treated with methotrexate for psoriatic arthritis and developed neutropenic sepsis after blood tests showed neutropenia and a raised CRP. He died in hospital on 15 April 2022 after developing ileitis and colitis, followed by cardiac arrest and multi-organ failure. Concerns included delays in triage, medical review and treatment; inadequate communication of information from community clinicians to hospital staff; and insufficient recognition of neutropenic sepsis risk factors and red flags.

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 emergency department capacity causing delays in triage, assessment and treatment
Wider context from the report
“1. When Mr Day arrived in ED, it was struggling to cope with a large backlog. Waiting times on that night /morning were significant. Triage wait times were approximately 1 hour. The time to see a doctor rose through the night to 7 hours and 38 minutes by 6am. The inquest heard that this was due to sheer volumes and that this is a situation that still arises. The impact is a delay in patients being seen, assessed and treated promptly; ”
Source location
Philip Geoffrey Day · 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
Publish a two-year delivery plan to recover urgent and emergency care services.

Verbatim wording from the response
“I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our 2-year Delivery plan for recovering urgent and emergency care services in January 2023, which aims to deliver sustained improvements in emergency waiting times. The ambition is to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022
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 5,000 additional staffed, permanent hospital beds to improve patient flow and reduce emergency-department overcrowding.

Verbatim wording from the response
“A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding. Further, we also achieved our target of scaling up virtual ward beds to over 10,000 in advance of winter.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022
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
Make £1.6 billion available over two years to support timely hospital discharge and reduce admission waits from emergency departments.

Verbatim wording from the response
“We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide 1:1 registered nurse staffing in the Emergency Department resuscitation area

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Unavailability of beds for emergency department patients

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.10

Concerns raised1

Failure to provide emergency department care in appropriate clinical spaces

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.5

Concerns raised1

Failure to provide sufficient designated clinical space for Emergency Department patients

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.9

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

Respondent positions 4

Actions described in response 10

Actions described in response 5

Actions described in response 9

Respondent positions 1