Recurring concern

Excessive emergency-department waiting times

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First reported 18 Oct 2016•Latest report 27 May 2025

Definition

What this concern includes

Includes excessive or unsafe waits for assessment, clinical review or onward care within emergency departments, including waits that cause patients to leave or avoid attending; include related crowding or operational failures only where they directly produce the unsafe emergency-department waiting time.

Not included

Excludes waiting times in hospitals, clinics or services outside emergency departments.
Excludes ambulance response, ambulance handover and hospital-admission delays unless the assertion directly concerns the emergency-department waiting time experienced by patients.
Excludes unsuitable waiting environments, staffing shortages or patient-flow failures where excessive emergency-department waiting time is not itself identified.
Excludes delays after the patient has received the relevant emergency-department assessment or has left the emergency department.

Reports: 7
Individual concerns: 10
Date range: 2016–2025
Stated actions: 33

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 Care5

Barnsley Hospital NHS Foundation Trust1

Barts Health NHS Trust1

Care Quality Commission1

NHS England1

the Dudley Group NHS Foundation Trust1

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.

27 May2025
East London
Concerns raised1
1. Excessive waiting times for assessment in Majors A&E
This report raised 6 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 5
1. Action
  Improve initial self-presenting patient assessment through a quality improvement project, assessment pathways and nursing education.
  Stated by Barts Health NHS TrustStated in progress
2. Action
  Operate a dedicated Fast Lane for walk-in emergency patient assessment and treatment.
  Stated by Barts Health NHS TrustStated completed
3. Action
  Expand Same Day Emergency Care capacity by enlarging space, merging clinical teams and increasing staffing.
  Stated by Barts Health NHS TrustStated completed
1. Action
  Increase senior resident staffing to provide greater senior oversight and earlier decisions in the emergency department.
  Stated by Barts Health NHS TrustStated planned
2. Action
  Use hospital-wide action cards to manage prolonged emergency department waits and escalate workload pressures.
  Stated by Barts Health NHS TrustStated completed
AI-generated summary

Abdirahman Afrah · 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

Abdirahman Afrah developed severe chest pain and attended A&E, but left without being seen by a doctor after a prolonged wait. He later collapsed at home and died in hospital on 4 June 2024 from bleeding caused by a pulmonary vascular malformation. The concerns included prolonged A&E waits, lack of timely medical triage, unclear communication about the urgency of returning to hospital, failure to discuss this directly with a responsible parent, and failure to send results to his GP in time.

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
Excessive waiting times for assessment in Majors A&E
Wider context from the report
“1. The inquest heard that waiting times to be seen in Majors A&E at Newham University Hospital could sometimes be between 9 to 14 hours. Many patients are unable to tolerate such long waits and leave the department before being seen. ”
Source location
Abdirahman Afrah · 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 initial self-presenting patient assessment through a quality improvement project, assessment pathways and nursing education.

Verbatim wording from the response
“There is an active quality improvement project ongoing which is aimed at improving processes for initial assessment of patients self-presenting to the emergency department. The aim of this project is to decrease initial assessment waiting times. In addition, there is a focused area for high-risk patients where there is increased availability of the RAT Dr to respond to queries, review patients, request imaging and start treatments. The project includes introducing easy to follow assessment”

Source location
2025-0245- Response from Barts Health NHS Foundation Trust
Page 2 · response
Published 29 May 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 Fast Lane for walk-in emergency patient assessment and treatment.

Verbatim wording from the response
“Since October 2024 we have introduced a new ‘Fast Lane’ for assessment and treatment of walk-in emergency patients. The provision of an area with consultation rooms and dedicated ED doctors has resulted in decreased waiting times for this group of patients and improved performance against the 4-hour target for non-admitted emergency patients from 50 to 65%.”

Source location
2025-0245- Response from Barts Health NHS Foundation Trust
Page 3 · response
Published 29 May 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
Expand Same Day Emergency Care capacity by enlarging space, merging clinical teams and increasing staffing.

Verbatim wording from the response
“Over the past 12 months we have expanded our physical space in the Same Day Emergency Care (SDEC) area. We have also merged our ambulatory medical and emergency medical clinical teams working in this area, with additional increase in clinical staffing numbers. This has allowed suitable patients to be directed to the most suitable clinical area and as a result this has reduced waiting times in the emergency department and improved patient experience. For example, patients presenting with chest pain follow one of the key pathways that can be assessed on SDEC, as well as easing the pressure on emergency patients in the main department.”

Source location
2025-0245- Response from Barts Health NHS Foundation Trust
Page 3 · response
Published 29 May 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 senior resident staffing to provide greater senior oversight and earlier decisions in the emergency department.

Verbatim wording from the response
“We have successfully recruited to all of our consultant vacancies in the last 6 months and will have a significant increase in senior residents managing the department from August 2025. This increase in senior decision makers will enhance the safety in the department overall, with senior oversight over the queue and earlier definitive decision making in the patient journey with a resultant reduction in waiting times.”

Source location
2025-0245- Response from Barts Health NHS Foundation Trust
Page 3 · response
Published 29 May 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
Use hospital-wide action cards to manage prolonged emergency department waits and escalate workload pressures.

Verbatim wording from the response
“Recognising that a functioning ED and manageable waiting times depend on a whole hospital response, ‘action cards’ have been created which give actions to ED nursing and medical teams, hospital site management and specialty teams to manage long waits in ED. Actions include direct referral to specialty teams to see patients, accessing escalation areas, triggering contact with Trust managers and directors to manage workload across the Group.”

Source location
2025-0245- Response from Barts Health NHS Foundation Trust
Page 4 · response
Published 29 May 2025
Open published response
19 Feb2025
Manchester South
Concerns raised2
1. Prolonged waits in Emergency Departments for ward beds
2. Recurring prolonged waits in Emergency Departments for ward beds
This report raised 6 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
  Publish the 2025 NHS mandate and planning guidance containing urgent-care delivery priorities and implementation targets.
  Stated by Department of Health and Social CareStated completed
2. Action
  Continue improving urgent and emergency care services to improve access and restore constitutional waiting-time performance.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Kenneth James CLAYTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kenneth James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.

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
Prolonged waits in Emergency Departments for ward beds
Wider context from the report
“1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Recurring prolonged waits in Emergency Departments for ward beds
Wider context from the report
“2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual. As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the 2025 NHS mandate and planning guidance containing urgent-care delivery priorities and implementation targets.

Verbatim wording from the response
“On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.”

Source location
Response from DHSC
Page 2 · response
Published 21 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 improving urgent and emergency care services to improve access and restore constitutional waiting-time performance.

Verbatim wording from the response
“The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. I would like to assure you we are committed to continuing to improve services to ensure patients can access the right care first time, only visiting A&E when necessary, and returning waiting times to the NHS constitutional standard where at least 95% of patients in A&E will be admitted, transferred or discharged within 4 hours.”

Source location
Response from DHSC
Page 1 · response
Published 21 February 2025
Open published response
4 Feb2025
North East Kent
Concerns raised3
1. Reluctance of patients to attend the emergency department because of long waiting times
2. Delays in emergency treatment caused by unavailable inpatient beds
3. Delays in emergency department patients being seen by a doctor
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Publish the NHS mandate and planning guidance prioritising and detailing improvements to A&E and ambulance waiting times.
  Stated by Department of Health and Social CareStated completed
2. 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
3. Action
  Continue operating-model work with regions to support providers in reducing Emergency Department crowding.
  Stated by NHS EnglandStated in progress
1. Action
  Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.
  Stated by NHS EnglandStated completed
2. 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
3. Action
  Increase the proportion of patients discharged by or on day seven of admission.
  Stated by Department of Health and Social CareStated planned
4. 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
5. 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
6. 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
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
8. Action
  Undertake regional Emergency Department quality and safety visits to identify challenges and support safe care and performance improvement.
  Stated by NHS EnglandStated completed
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
Reluctance of patients to attend the emergency department because of long waiting times
Wider context from the report
“(3) When asked about whether the delays led to a risk of deaths to others evidence was brought to the courts attention that the President of the Royal College of Emergency Medicine has published an analysis of the impact that this is having and that there are a significant number deaths associated with long waits in the emergency department. This, in conjunction with the reluctance of patients to attend the emergency department due to long waiting times clearly gives rise to a risk of future deaths unless something is done. ”
Source location
Dorothy Lilian REID · Prevention of Future Deaths report
Page 3 · 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
Delays in emergency treatment caused by unavailable inpatient beds
Wider context from the report
“(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem. ”
Source location
Dorothy Lilian REID · Prevention of Future Deaths report
Page 3 · 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
Delays in emergency department patients being seen by a doctor
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
Publish the NHS mandate and planning guidance prioritising and detailing improvements to A&E and ambulance waiting times.

Verbatim wording from the response
“On 30 January 2025, the Government published ‘Road to recovery: the government’s 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.”

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 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
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
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
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
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 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
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
Undertake regional Emergency Department quality and safety visits to identify challenges and support safe care and performance improvement.

Verbatim wording from the response
“NHS England’s South East region has undertaken Quality & Safety visits to EDs across the region to understand the challenges faced in delivering safe and effective care. This has identified next steps, to include sharing learning and best practice, and ensuring a quality and safety focus on performance recovery and improvement.”

Source location
Response from NHS England
Page 3 · response
Published 7 February 2025
Open published response
25 Mar2024
Cornwall and Isles of Scilly
Concerns raised1
1. Crowding and extremely long waiting times in the emergency department
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 5
1. Action
  Publish and implement the delivery plan for recovering urgent and emergency care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Maintain the uplift of 5,000 staffed, permanent hospital beds delivered through the urgent and emergency care plan.
  Stated by Department of Health and Social CareStated completed
3. Action
  Invest an additional £1 billion through the Discharge Fund to support timely and effective hospital discharge.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Ensure every acute hospital has access to a care transfer hub supporting complex discharges and early planning.
  Stated by Department of Health and Social CareStated completed
2. Action
  Continue working with NHS England to reduce patient waiting times.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

ROBERT ANDREW PROWSE · 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

Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.

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
Crowding and extremely long waiting times in the emergency department
Wider context from the report
“9. The court heard evidence that Treliske have established a triage centre in the car park, known as the Rapid Assessment and Treatment Centre. The primary purpose of triage is to identify those patients in immediately life-threatening condition. The triage centre is an attempt to mitigate the risks due to ambulance delay and overcrowding in ED. ████████ stated that the vast majority of patients are now seen in the car park, inside ambulances or in the triage centre, rather than in ED. 10. The court heard evidence of crowding at Treliske ED with patients being accommodated in the corridors. Evidence was heard from ████████ regarding a scientific study by Royal College of Emergency Medicine (published in the Emergency Medicine Journal). This study discussed the adverse impact of crowding in ED. The study calculated the estimated number of excess deaths occurring across the United Kingdom associated with crowding and extremely long waiting times. The study showed that for every 72 patients waiting between eight- and 12-hours from their time of arrival in the Emergency Department there is one patient death. 11. The court heard evidence that in September 2023 patients had spent a total of 14,327 hours in Treliske ED when it was clinically appropriate for these patients to be discharged or moved to a ward. This period of time is equivalent to closing 19 cubicles in Treliske ED for a whole month. Treliske ED has 26 cubicles. ”
Source location
ROBERT ANDREW PROWSE · 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
Publish and implement the delivery plan for recovering urgent and emergency care services.

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. Our ambition for this year is to reduce Category 2 ambulance response times to 30 minutes on average. 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 3 April 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
Maintain the uplift of 5,000 staffed, permanent hospital beds delivered through the urgent and emergency care plan.

Verbatim wording from the response
“Your report also highlights that Royal Cornwall Hospital was experiencing high demand with long handover delays. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals, as you rightly identify in your report, 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. We have 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 12,000 beds available nationally.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 3 April 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
Invest an additional £1 billion through the Discharge Fund to support timely and effective 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 3 April 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
Ensure every acute hospital has access to a care transfer hub supporting complex discharges and early planning.

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 3 April 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 working with NHS England to reduce patient waiting times.

Verbatim wording from the response
“However, I recognise there is still more to do to reduce patient waiting times further, and the Government will continue to work with NHS England to achieve this.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 3 April 2024
Open published response
4 Feb2023
Manchester South
Concerns raised1
1. Delays in patients being seen in Accident and Emergency
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 3
1. Action
  Publish a delivery plan to recover urgent and emergency care services and improve emergency waiting times.
  Stated by Department of Health and Social CareStated completed
2. Action
  Deliver 5,000 additional staffed, permanent hospital beds to increase capacity and improve patient flow.
  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 free beds.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Benjamin Paul Stanley · 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

Benjamin Paul Stanley developed chronic pancreatitis, became severely malnourished, and was admitted to Stepping Hill Hospital on 11 May 2022. He deteriorated, developing liver cirrhosis, sepsis and a Clostridium difficile infection, and died in hospital on 19 May 2022. The concerns identified included prolonged waits in A&E linked to demand and a lack of beds; in his case, direct entry to a ward was considered to have been in his best interests, but he had to wait in A&E for a bed.

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 patients being seen in Accident and Emergency
Wider context from the report
“The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department. The Inquest heard that the hospital had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment. The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester. The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital. In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed. ”
Source location
Benjamin Paul Stanley · 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 delivery plan to recover urgent and emergency care services and improve emergency waiting times.

Verbatim wording from the response
“As the Minister responsible for urgent and emergency case services, I recognise the pressures our A&E services are facing and the impact on waiting times for patients. That is why we published our delivery plan for recovering urgent and emergency care services 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 1 · response
Published 20 February 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 to increase capacity and improve patient flow.

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”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 20 February 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
Make £1.6 billion available over two years to support timely hospital discharge and free beds.

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. NHS England also launched its universal support offer, available to all systems, including Stockport NHS Foundation Trust which supported systems to implement high impact initiatives and improve emergency care performance ahead of winter this year.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 20 February 2023
Open published response
19 Sep2018
Black Country
Concerns raised1
1. Excessive waiting times for patients to be seen by clinicians in the emergency department
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 6
1. Action
  Implement a nationally recognised triage tool and audit triage timeliness and quality.
  Stated by the Dudley Group NHS Foundation TrustStated completed
2. Action
  Expand the triage area to increase patient capacity, privacy and dignity.
  Stated by the Dudley Group NHS Foundation TrustStated completed
3. Action
  Provide rapid patient observations during periods of high demand.
  Stated by the Dudley Group NHS Foundation TrustStated completed
1. Action
  Implement an Emergency Department escalation plan and an in-reach process.
  Stated by the Dudley Group NHS Foundation TrustStated completed
2. Action
  Increase physician presence in the Emergency Department.
  Stated by the Dudley Group NHS Foundation TrustStated completed
3. Action
  Provide additional assistance to the Emergency Department during periods of high demand.
  Stated by the Dudley Group NHS Foundation TrustStated completed
AI-generated summary

Hubert Kelly · 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

Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.

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
Excessive waiting times for patients to be seen by clinicians in the emergency department
Wider context from the report
“1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors; 2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area; 3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours. ”
Source location
Hubert Kelly · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a nationally recognised triage tool and audit triage timeliness and quality.

Verbatim wording from the response
“The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand the triage area to increase patient capacity, privacy and dignity.

Verbatim wording from the response
“The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide rapid patient observations during periods of high demand.

Verbatim wording from the response
“The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an Emergency Department escalation plan and an in-reach process.

Verbatim wording from the response
“The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase physician presence in the Emergency Department.

Verbatim wording from the response
“The Trust has implemented an escalation plan and a process of in-reach with ED and increased physician presence. We attached a weekly return which documents the impact of this and”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide additional assistance to the Emergency Department during periods of high demand.

Verbatim wording from the response
“demonstrates that the interest of patients is prioritised. At times of high demand there is a new process of providing additional help to the Emergency Department too.”

Source location
Hubert-Kelly-Response
Page 2 · response
Published 19 September 2018
Open published response
18 Oct2016
South Yorkshire (Western)
Concerns raised1
1. Delays in medical assessment of patients with classical DVT/PE symptoms
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 1
1. Action
  Provide consultant-led senior assessment in the START emergency assessment hub during its operating hours.
  Stated by Barnsley Hospital NHS Foundation TrustStated completed
AI-generated summary

Captain James Michael Bedford · 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

Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

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 medical assessment of patients with classical DVT/PE symptoms
Wider context from the report
“3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter). ”
Source location
Captain James Michael Bedford · 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
Provide consultant-led senior assessment in the START emergency assessment hub during its operating hours.

Verbatim wording from the response
“3. In the Emergency Department (ED) there is now a consultant in the new assessment hub area, which should speed up the diagnosis and management of someone presenting in this way. The Short-Term Assessment of Risk and Treatability Hub (START) runs between the hours of 09:00 and 16:00 hours and is consultant led. The START consultant will provide a senior ‘front of house’ service to assist with the initial assessment and ensure the appropriate diagnostic testing is undertaken at the earliest opportunity. The Consultant will work alongside the assessment hub staff in ensuring a safe and rapid assessment process. The consultant predominantly receives patients arriving by ambulance, however patients that also ‘self present’ can be seen on START, if they are unwell, have an elevated NEWS score or require treatment within one hour.”

Source location
2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Excessive waiting times for assessment in Majors A&E

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 raised2

Prolonged waits in Emergency Departments for ward beds

Recurring prolonged waits in Emergency Departments for ward beds

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.2

Concerns raised3

Reluctance of patients to attend the emergency department because of long waiting times

Delays in emergency treatment caused by unavailable inpatient beds

Delays in emergency department patients being seen by a doctor

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.11

Concerns raised1

Crowding and extremely long waiting times in the emergency department

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

Actions described in response 5

Actions described in response 2

Actions described in response 11

Actions described in response 5