Recurring concern

Failure to maintain safe hospital patient flow

First to latest report 19 Feb 2015 — 18 Jun 2026

Reports that mention this concern
33
Times this concern has been raised
37
Stated actions linked to this concern
115

What this concern includes

Includes failures in the end-to-end hospital patient-flow process, including ambulance-to-Emergency-Department transfer, Emergency Department admission and throughput, movement into wards, bed and resource coordination, discharge-related flow constraints and associated escalation or coordination controls where these directly leave patients waiting or obstruct safe movement through hospital care.

What is not included
  • Excludes generic ambulance response delays, clinical treatment delays or hospital handover failures when they are not part of a wider hospital patient-flow problem.
  • Excludes the underlying shortage of a specific resource, bed type or care package when no resulting hospital patient-flow failure is asserted.
  • Excludes failures confined to a separately named process such as hospital bed-management systems, Emergency Department triage, discharge planning or social-care provision when that narrower process is the shared unsafe condition.
  • Excludes routine patient-flow descriptions or isolated delays without a continuing or system-level unsafe condition.

Reports and published responses 33 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Wiltshire and Swindon

    AI-generated summary

    Richard Carpenter · 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

    Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of sufficient free hospital beds due to bed blocking

    Wider context from the report

    “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community. This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion. ”

    Source location

    Richard Carpenter · 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 £1 billion to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.

    Verbatim wording from the response

    “Your report highlights that SWAST were responding to high demand. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 30 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 £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.

    Verbatim wording from the response

    “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 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

    Launch a £40 million fund for local authorities facing significant urgent and emergency care pressures.

    Verbatim wording from the response

    “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 April 2024

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    PATRICIA ANNE VAN DER EYKEN · 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

    Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by 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

    Failure to transfer patients from emergency departments to hospital wards when clinically indicated

    Wider context from the report

    “8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. This leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department. It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The report stated: “It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance”. 9. The investigation report states ‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents. With fewer resources on the road, the response times to patients inevitably increases… ….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.” 10. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts. ”

    Source location

    PATRICIA ANNE VAN DER EYKEN · 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

    Provide £1 billion to increase staffed core hospital beds by 5,000 and improve patient flow and bed capacity.

    Verbatim wording from the response

    “Your report highlights that SWAST and local hospitals were experiencing high demand and long handover delays. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 3 April 2024

    Open published response

  3. Cornwall and Isles of Scilly

    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

    Failure to transfer emergency department patients to hospital wards when clinically indicated

    Wider context from the report

    “6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge. 7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity. 8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. ”

    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

    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

  4. Cornwall and Isles of Scilly

    AI-generated summary

    John Charles Seagrove and 2 others · 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

    The report concerns the deaths of John Charles Seagrove, Pauline Mary Humphris and Patricia Joan Steggles, following delays in emergency ambulance response and in handing patients over to hospital staff. The report raises concerns about worsening emergency department pressures, with ambulances waiting outside, and reported burnout and recruitment difficulties among healthcare staff. In Mrs Humphris’s case, the coroner found that ambulance and hospital admission delays may have contributed to the outcome; in Mrs Steggles’s case, the inquest heard that earlier hospital arrival would probably have led to survival.

    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 timely ambulance access to the ED

    Wider context from the report

    “It was acknowledged in the evidence that matters had improved over the summer this year. What is of concern, however, is that these gains have not been maintained and the situation has now worsened with 15-20 ambulances waiting outside the ED on occasions over the last three weeks. I have spoken to the Medical Director at RCHT, ████████, and he has confirmed that is the current position. This concern is compounded by the recognition that we are yet to experience the additional pressures that winter will bring. Additionally, I am now hearing evidence at inquest of ‘burn-out’ among paramedics, nurses and doctors. At the inquest into the death of Mrs Steggles, I was advised that the hospital is now finding it difficult to recruit to vacant positions. ”

    Source location

    John Charles Seagrove and 2 others · 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

    Deliver 5,000 additional staffed, permanent hospital beds and maintain the resulting capacity uplift.

    Verbatim wording from the response

    “I recognise that ambulance trusts work within a health 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. We also have 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 29 November 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Scale up national virtual ward capacity to more than 11,000 available beds.

    Verbatim wording from the response

    “I recognise that ambulance trusts work within a health 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. We also have 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 29 November 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 £1.6 billion over two years to support timely and effective hospital discharge.

    Verbatim wording from the response

    “I recognise that ambulance trusts work within a health 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. We also have 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 29 November 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

    Specific local urgent and emergency care improvements are best addressed by SWAST, the hospital trust and the local Integrated Care Board.

    Verbatim wording from the response

    “Your report raises concerns about the response time performance of the South Western Ambulance Service NHS Foundation Trust (SWAST), ambulances queueing as a result of patient handover delays at the Royal Cornwall Hospital, and the pressures being felt by paramedics, nurses and doctors. You have also raised these concerns with the ambulance service and the hospital trust, as well as with the local Integrated Care Board as copied interested parties. These NHS organisations are best placed to respond on the specific action being taken locally to improve urgent and emergency care services.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 29 November 2023

    Open published response

  5. Manchester South

    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

  6. Manchester South

    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

    Failure of ward discharge processes to maintain patient flow

    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 individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in ambulance access and transfer to Emergency Departments

    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

    Provide two-year funding to support timely and effective hospital discharge.

    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

    Fund additional ambulance capacity and maintain the resulting capacity uplift through 2024/25.

    Verbatim wording from the response

    “Regarding ambulance response times, a primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

    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

    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

    Continue working with NHS England to reduce ambulance response times and A&E waiting times.

    Verbatim wording from the response

    “However, I recognise there is still more to do to reduce response times and waiting times further, and the Government will continue to work with NHSE to achieve this.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 21 July 2023

    Open published response

  7. North Wales (East and Central)

    AI-generated summary

    Philip Hawkins · 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 Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and 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 allocation of hospital beds from the Emergency Department

    Wider context from the report

    “Entry into Hospital and Delay to bed allocation 1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED). 2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day. 3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23. ”

    Source location

    Philip Hawkins · 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

    Delays in entry into hospital from ambulance arrival

    Wider context from the report

    “Entry into Hospital and Delay to bed allocation 1. Mr Hawkins arrived at hospital at 13:25 on 18.03.23 and remained in the ambulance until 23:42 when he was ‘offloaded’ onto a corridor in the Emergency Department (ED). 2. He was moved to a rapid assessment room in the ED at 11:33 on 19.03.23 and then into a cubicle at 21:47, the same day. 3. Mr Hawkins was eventually allocated to a bed from the ED, at 19:17 on 20.03.23. ”

    Source location

    Philip Hawkins · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Norfolk

    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

  9. Manchester South

    AI-generated summary

    James Robert Curry · 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

    James Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.

    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 timely bed access for elderly patients with hip fracture

    Wider context from the report

    “1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”

    Source location

    James Robert Curry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Norfolk

    AI-generated summary

    Michael Nestor WYSOCKYJY · 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

    Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.

    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

    Inability to offload ambulances promptly, delaying access to x-ray

    Wider context from the report

    “1. The ED was busy at the time and unable to offload ambulances. An x-ray cannot be carried out on an ambulance and must wait until the patient is in ED. If the patient remains on the ambulance for several hours this can delay the x-ray taking place. ”

    Source location

    Michael Nestor WYSOCKYJY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Physical constraints prevent X-rays on ambulances; no alternative exists beyond careful clinical assessment during busy periods.

    Verbatim wording from the response

    “Response: It is correct to say that an X-ray cannot be undertaken on an ambulance because the radiology equipment that generates ionising radiation is insufficiently mobile and too large to be used in this setting. If it is thought by the assessing clinician who goes on to the ambulance that a patient’s need for an X-ray is urgent or an emergency, that patient will be prioritised to be removed from the vehicle as soon as possible. Although conditions for patients are not ideal whilst waiting to enter the Emergency Department, in this way their clinical needs in terms of urgent imaging remain the same as if the patient had already been transferred into the department.”

    Source location

    Response from NHS Queen Elizabeth Hospital Kings's Lynn
    Page 1 · response
    Published 24 May 2022

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026