Concerns raised 1
Failure to maintain emergency department capacity and timely patient flow View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Geoffrey Gordon Fuller · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain emergency department capacity and timely patient flow
Wider context from the report “1. On the day of Mr Fuller’s ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients . ED accommodated the surplus patients on trolleys in corridors, seated within the waiting room or remaining inside ambulances in the parking area outside ED.
2. The situation had not improved as at the date of this Inquest.
3. EDs have a national target for 95% of patients to be admitted, transferred or discharged within 4 hours. It was noted that there is a recent major study which shows that the standardised mortality rate starts to rise from 5 hours after the patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is one extra death for every 82 patients delayed. This increased mortality is partly attributed to the fact that patients in ED are not receiving the surgery or specialist care that is available on the wards.
4. Data indicates that RCHT have been failing to meet the 4-hour target for a significant number of patients. For the opening months of 2026 approximately 50% of patients have still been in ED after 4 hours .
5. RCHT witnesses reported that over the last few weeks the ED has been regularly required to accommodate over 100 patients (in a unit with a capacity for 42 patients) . This has involved significant numbers of patients still in ED after 12 hours, some still in ED after 24 hours .
” Source location Geoffrey Gordon Fuller · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest over £450 million to expand urgent and emergency care capacity through the 2025/26 delivery plan.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.
Verbatim wording from the response “We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care.” Source location Response from Department of Health and Social Care
Open published response
12 Feb 2026 Barry HARMER · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 1
Inconsistent operation of daily patient flow meetings View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Barry HARMER · 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
Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent operation of daily patient flow meetings
Wider context from the report “(2) At the Inquest there was variable evidence as to the operation of the daily Patient Flow Meetings , during which patients requiring beds would be matched to availability based on individual needs. Communication to families of issues or obstructions to bed availability and reinforcement of safety plans during any period of wait for a bed should be a central feature of these daily meetings.
” Source location Barry HARMER · Prevention of Future Deaths report
Open source report
7 Feb 2026 Janet Springall · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1
Delays in transferring unwell patients from ambulances to the emergency department View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Publish national urgent and emergency care, medium-term planning, and 10-year health plans setting priorities for ambulance response, handovers, flow, discharge, and urgent care access.
View source
Department of Health and Social Care
Mandate the Release to Rescue approach, requiring ambulance handover to begin at 30 minutes and finish within 45 minutes.
View source
Department of Health and Social Care
Continue working with integrated care boards, acute trusts, and ambulance services to deliver the 45-minute handover limit, strengthen urgent community care, and improve hospital flow and discharge.
View source
Care Quality Commission
Re-emphasise safe clinical escalation processes for patients awaiting ambulance offload, including when clinical staff should attend patients outside the department.
View source
Care Quality Commission
Continue monitoring ambulance handover delays and their impact on patient safety through regulatory activity and evidence from patients, staff, ambulance services and system partners.
View source
Care Quality Commission
Continue using regulatory powers to ensure the trust maintains systems identifying deteriorating patients, including those waiting outside the department, and manages emergency-care pathway risks.
View source See 3 more actions
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AI-generated summary
Janet Springall · 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
Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased risk.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in transferring unwell patients from ambulances to the emergency department
Wider context from the report “My concern is that notwithstanding the hospital Trust seems to have made welcome improvements, patients such as Janet Springall remain at risk.
The Trust continues to experience significant pressures due to patient numbers, and unwell patients continue to remain in ambulances for some time before they are able to access the emergency department.
When a very unwell patient has to remain on an ambulance due to very high demands placed upon a hospital emergency department , believed by paramedics to have a life-threatening infection, then in the absence of a blood test and the timely administration of any necessary intravenous fluids and antibiotics, the chances of such a patient surviving can be significantly reduced by the time the patient is able to access the emergency department .
Janet Springall was very unwell by the time she arrived at hospital and was likely to die. Any realistic prospect she may recover had subsided by around 7.30pm, some 2.5 hours after arrival at hospital.
Other patients may not be as unwell as Janet was upon arrival at hospital, and may therefore have more chance of surviving, but they too may deteriorate significantly whilst remaining in the ambulance before it can be confirmed they have an infection and receive timely medical attention and treatment.
I believe it is necessary for to raise this concern, but it is not for me to be prescriptive about what should / can be done.
” Source location Janet Springall · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish national urgent and emergency care, medium-term planning, and 10-year health plans setting priorities for ambulance response, handovers, flow, discharge, and urgent care access.
Verbatim wording from the response “NHS England and the Department of Health and Social Care recognise the ongoing pressures across urgent and emergency care, including ambulance services. To improve the quality and timeliness of patient care, the Department of Health and Social Care and NHS England published the 2025/26 Urgent and Emergency Care Plan (June 2025), the Medium Planning Framework 2026-27 to 2028/29 and the 10-Year Health Plan for England: Fit for the Future (July 2025). These set out key system priorities:” Source location Response from Department for Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mandate the Release to Rescue approach, requiring ambulance handover to begin at 30 minutes and finish within 45 minutes.
Verbatim wording from the response “Over £370 million in national capital funding supported these improvements. The plans also commit to shifting focus from treatment to prevention, reducing pressure on urgent and emergency care. To ensure timely patient care and release ambulances back into the community, the plan mandates the “Release to Rescue” approach. This requires the handover process to begin at 30 minutes and be completed by 45 minutes.” Source location Response from Department for Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with integrated care boards, acute trusts, and ambulance services to deliver the 45-minute handover limit, strengthen urgent community care, and improve hospital flow and discharge.
Verbatim wording from the response “NHS England continues to work with ICBs, acute trusts, and ambulance services to deliver the 45-minute maximum handover requirement, strengthen urgent community care, and improve hospital flow and discharge. Risks associated with long community waits for ambulances are regularly discussed at national forums to support shared understanding and coordinated action across the urgent and emergency care system. The Medium-Term Planning Framework (2026/27–2028/29) sets further ambitions for acute and ambulance collaboration, including progress toward the 15-minute handover standard.” Source location Response from Department for Health and Social Care
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Re-emphasise safe clinical escalation processes for patients awaiting ambulance offload, including when clinical staff should attend patients outside the department.
Verbatim wording from the response “CQC will:” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue monitoring ambulance handover delays and their impact on patient safety through regulatory activity and evidence from patients, staff, ambulance services and system partners.
Verbatim wording from the response “CQC will:” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue using regulatory powers to ensure the trust maintains systems identifying deteriorating patients, including those waiting outside the department, and manages emergency-care pathway risks.
Verbatim wording from the response “CQC will continue to use its regulatory powers to ensure that the trust maintains effective systems to identify deteriorating patients, including those waiting outside the department, and manages risks within the emergency care pathway.” Source location Response from Care Quality Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Care Quality Commission will provide a separate response to the concerns.
Verbatim wording from the response “In preparing this response, my officials have made enquiries with NHS England and Blackpool Teaching Hospital NHS Trust to ensure we adequately address your concerns. CQC have advised they will be providing a separate response to your concerns.” Source location Response from Department for Health and Social Care
Open published response
3 Nov 2025 Kathleen Rose WARD · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1
Failure to move people requiring ward-based care out of the emergency department View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kathleen Rose WARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kathleen Rose WARD, who had terminal mesothelioma, was admitted to Hull Royal Infirmary’s emergency department on 19 February 2025 because no bed was available at Queens Centre. She remained there for 21 hours and died at Hull Royal Infirmary on 20 February 2025; the inquest recorded pneumonia as the immediate cause of death, with mesothelioma, immunotherapy-induced myocarditis and chronic kidney disease contributing. The principal concern was that insufficient specialist end-of-life bed capacity resulted in patients receiving palliative care in unsuitable emergency-department environments, with potential delays to appropriate emergency treatment.
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× 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 move people requiring ward-based care out of the emergency department
Wider context from the report “1. During the evidence it was heard that the emergency department still has people being held in their department who should be getting ward based care . Additionally, that there has been no increase in the bed space available for Queens Centre. This meant that I could have no reassurance that the circumstances of Mrs Ward’s death would not be repeated, but also that people requiring emergency treatment may be delayed in receiving the appropriate emergency care.
” Source location Kathleen Rose WARD · Prevention of Future Deaths report
Open source report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Model beds, review discharge processes, and work with community partners to improve specialist and acute bed flow.
Verbatim wording from the response “The Trust is undertaking ongoing initiatives to bed model, review processes to maximise discharges, and work with community partners to support patients who require social care. These actions are consistent with national guidance and aim to improve flow through the acute bed base, including specialist oncology beds.” Source location Response from Hull Royal Infirmary
Open published response
28 Oct 2025 Lewis Aubrey GARFIELD · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 2
Delays in transferring patients from the Emergency Department into wards View source Delays in transferring ambulance patients into the Emergency Department View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care University Hospitals of Northamptonshire NHS Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
University Hospitals of Northamptonshire NHS Group
Implement a standardised Transfer of Care form across the organisation to improve discharge-hub referrals.
View source
University Hospitals of Northamptonshire NHS Group
Reopen Sir Thomas Moore Ward as a 24/7 discharge lounge, adding 14 bed spaces and eight chairs.
View source
University Hospitals of Northamptonshire NHS Group
Hold twice-weekly system-partner escalation calls to support complex discharges.
View source
Department of Health and Social Care
Improve hospital patient flow, increase four-hour emergency-department performance to 78%, reduce 12-hour waits and tackle discharge delays.
View source
Department of Health and Social Care
Implement additional winter surge capacity across urgent and emergency care services.
View source
Department of Health and Social Care
Increase staffing to mitigate seasonal urgent and emergency care pressures.
View source
University Hospitals of Northamptonshire NHS Group
Formalise direct ambulance pathways to Same Day Emergency Care and extend operating hours.
View source
University Hospitals of Northamptonshire NHS Group
Launch Rapid Assessment and Acute Assessment Units to expand ambulance handover capacity and stream patients directly into acute assessment.
View source
University Hospitals of Northamptonshire NHS Group
Introduce a NerveCentre pre-arrival screen using ambulance clinical histories to prepare handovers before arrival.
View source
University Hospitals of Northamptonshire NHS Group
Commission eight additional Rapid Assessment Unit trolley spaces at Northampton General Hospital for primary assessment and faster handover.
View source
University Hospitals of Northamptonshire NHS Group
Continue working with system partners to reduce delay impacts and implement the national 45-minute maximum ambulance handover standard.
View source
Department of Health and Social Care
Enable ambulance services to convey patients directly to non-emergency-department facilities, including same-day emergency care services.
View source See 9 more actions
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AI-generated summary
Lewis Aubrey GARFIELD · 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
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
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× 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 transferring patients from the Emergency Department into wards
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards , causes delays taking patients from ambulances into ED, and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” Source location Lewis Aubrey GARFIELD · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in transferring ambulance patients into the Emergency Department
Wider context from the report “f) The delays getting patients from the Emergency Department (ED) into wards, causes delays taking patients from ambulances into ED , and a knock-on delay getting ambulances back out into the community. These delays persist despite the current actions to mitigate.
” Source location Lewis Aubrey GARFIELD · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a standardised Transfer of Care form across the organisation to improve discharge-hub referrals.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reopen Sir Thomas Moore Ward as a 24/7 discharge lounge, adding 14 bed spaces and eight chairs.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold twice-weekly system-partner escalation calls to support complex discharges.
Verbatim wording from the response “| Improved discharge planning and boardround documentation.
May 2025 | Release to Respond Go live NGH. | Implement release to respond model with key escalation triggers to balance clinical risk across the organisation.
June 2025 | NyeBevan move to medicine specialty only and address backflow of patients with GIRFT. | Reduced LoS on NyeBevan with reduced medical outliers in surgical wards.
July 2025 | Use of Siren to review patient identifiable information from EMAS pre arrival. | Reduce delays associated with registration of patients into EPR.
Sept 2025 | Twice weekly system partner escalation calls for complex discharge support. | Improvement in super stranded position across UHN.
Oct 2025 | Cardiology Virtual Ward launched at NGH. | Reduce length of stay through virtual monitoring of heart failure patients who would otherwise meet criteria to reside.” Source location Response from University Hospitals of Northamptonshire
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve hospital patient flow, increase four-hour emergency-department performance to 78%, reduce 12-hour waits and tackle discharge delays.
Verbatim wording from the response “We are taking serious steps to achieve this. We published our Urgent and Emergency Care Plan for 2025/26 which focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement additional winter surge capacity across urgent and emergency care services.
Verbatim wording from the response “Regarding your concerns for the upcoming winter, we have implemented additional surge capacity, increased staffing, and enhanced coordination across services to mitigate seasonal pressures. This includes running stress test exercises and offering health checks to the most vulnerable.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase staffing to mitigate seasonal urgent and emergency care pressures.
Verbatim wording from the response “Regarding your concerns for the upcoming winter, we have implemented additional surge capacity, increased staffing, and enhanced coordination across services to mitigate seasonal pressures. This includes running stress test exercises and offering health checks to the most vulnerable.” Source location Response from Department for Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formalise direct ambulance pathways to Same Day Emergency Care and extend operating hours.
Verbatim wording from the response “Date | Action Implemented | Impact
Mar 2025 | Implementation of a standardised Transfer of Care (TOC) form across UHN. | Improve quality and reduce delays associated with TOC referrals into the discharge hub.
Mar 2025 | Frailty SDEC go live KGH. | Dedicated capacity for Frailty SDEC service.
Mar 2025 | Agreement of Internal Professional Standards across UHN. | Expectations on timeliness of specialty support and escalation.
Apr 2025 | Sir Thomas Moore Ward (KGH) reopened to adult patients for 24/7 discharge lounge. | 14 additional bed spaces and 8 chairs for patients planned discharge to reduce length of stay.
Apr 2025 | Formalised direct to SDEC pathways for EMAS and extended operating hours. | 15% increase in SDEC activity to reduce ED attendance and overcrowding.
Apr-May 2025 | Boardround test for change and Boardround SOP (NGH).” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch Rapid Assessment and Acute Assessment Units to expand ambulance handover capacity and stream patients directly into acute assessment.
Verbatim wording from the response “Oct 2025 | Frailty SDEC go live NGH. | Frailty team based in medical SDEC for specialty assessment.
Oct 2025 | Trusted Assessor introduced at NGH. | Reduce discharge delays for patients returning to care homes.
Nov 2025 | Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. | Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand.
Dec 2025 | Introduction of nerve centre pre arrivals screen | Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a NerveCentre pre-arrival screen using ambulance clinical histories to prepare handovers before arrival.
Verbatim wording from the response “Oct 2025 | Frailty SDEC go live NGH. | Frailty team based in medical SDEC for specialty assessment.
Oct 2025 | Trusted Assessor introduced at NGH. | Reduce discharge delays for patients returning to care homes.
Nov 2025 | Rapid Assessment Unit (RAU) and Acute Assessment Unit (AAU) go live. | Increase in capacity of ambulance handover space and medical pathway directly into AAU reducing ED demand.
Dec 2025 | Introduction of nerve centre pre arrivals screen | Improvement in <15min handovers as EMAS Siren clinical history added as pre arrival ready for handover once ambulance arrives to site.” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Commission eight additional Rapid Assessment Unit trolley spaces at Northampton General Hospital for primary assessment and faster handover.
Verbatim wording from the response “As of Monday 3rd November at NGH, a new purpose built Rapid Assessment Unit (RAU) was commissioned providing 8 additional trolley spaces aimed at handover within 15mins into a dedicated space for primary assessment of patients. This forms a key part of strategic planning that will see a new Urgent Treatment Centre open from July 2026 with works already having commenced.” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with system partners to reduce delay impacts and implement the national 45-minute maximum ambulance handover standard.
Verbatim wording from the response “Overcrowding in the Emergency Department is well recognised as impacting on quality and safety, increasing risk of harm to patients if unable to handover from ambulances. This risk is actively monitored through the Trust Accountability Framework with performance and actions reviewed through Divisional Accountability meetings, Clinical Quality and Safety Committee in Common, Trust Board and ICB UEC Board. In line with this year’s 2025/26 planning guidance and Urgent and Emergency Care Recovery plan a 45min handover ceiling has been worked towards in close collaboration with EMAS colleagues both at Directorate and Director level.” Source location Response from University Hospitals of Northamptonshire
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable ambulance services to convey patients directly to non-emergency-department facilities, including same-day emergency care services.
Verbatim wording from the response “We are taking serious steps to achieve this. We published our Urgent and Emergency Care Plan for 2025/26 which focuses on improvements to deliver better UEC performance both daily and during winter pressures, ensuring more patients receive timely and clinically appropriate care. Key actions include:” Source location Response from Department for Health and Social Care
Open published response
Concerns raised 1
ED crowding delaying patient access to surgery or specialist treatment View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.
View source
Department of Health and Social Care
Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
View source
Department of Health and Social Care
Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
View source
Department of Health and Social Care
Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
View source
Department of Health and Social Care
Set out lessons learned from winter urgent and emergency care pressures.
View source
Department of Health and Social Care
Put improvements in place to further improve urgent and emergency care services during 2025/26.
View source See 3 more actions
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AI-generated summary
Andrew Waters · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation ED crowding delaying patient access to surgery or specialist treatment
Wider context from the report “(2) ED crowding leading to increased risk in mortality for patients being held in ambulances and corridors and being delayed from receiving surgery or specialist treatment on wards .
” Source location Andrew Waters · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the 2025 mandate to NHS England, prioritising improvements to A&E and ambulance waiting times.
Verbatim wording from the response “On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
Verbatim wording from the response “Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
Verbatim wording from the response “In January 2025, we also published a new policy framework for the £9 billion Better Care Fund. Under the new framework, the NHS and local authorities have clear accountability for setting and achieving joint goals that include reducing discharge delays.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Set out lessons learned from winter urgent and emergency care pressures.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put improvements in place to further improve urgent and emergency care services during 2025/26.
Verbatim wording from the response “In addition, we will also shortly set out the lessons learned from the pressures on urgent and emergency care services this winter and the improvements that we will put in place to further improve services during 2025/26.” Source location Response from DHSC
Open published response
19 Feb 2025 Kenneth James CLAYTON · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Prolonged waits in Emergency Departments for ward beds View source Recurring prolonged waits in Emergency Departments for ward beds View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Kenneth James CLAYTON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.
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
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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue 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
Open published response
24 Nov 2024 Colin Wiles · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 1
Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England NHS Humber Health Partnership
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 15
NHS Humber Health Partnership
Implement the phased 045 Handover Plan to reduce ambulance handover times toward a 45-minute target.
View source
NHS Humber Health Partnership
Activate the Ambulance Delay Protocol, including site escalation, rapid patient transfers, and prioritisation of suitable patients.
View source
NHS Humber Health Partnership
Revise the operating procedure to offload up to eight ambulances hourly and transfer ten patients from the Emergency Department to inpatient wards.
View source
NHS Humber Health Partnership
Implement Pull for Safety to maintain regular patient flow from the Emergency Department to assessment areas and wards.
View source
NHS Humber Health Partnership
Use escalation areas and reverse boarding protocols to create immediate capacity for arriving patients.
View source
NHS Humber Health Partnership
Implement the Temporary Escalation Space and Boarding SOP to manage capacity challenges, patient boarding, and timely Emergency Department handovers.
View source
NHS Humber Health Partnership
Open and operate a 54-bed NCTR unit to accommodate patients awaiting discharge and reduce reliance on acute beds.
View source
NHS Humber Health Partnership
Implement updated discharge protocols covering local-authority coordination, family and carer involvement, and care transfer hubs.
View source
NHS Humber Health Partnership
Conduct board rounds and huddles to identify discharges early and meet ward discharge targets of 30% by noon and 70% by 17:00.
View source
NHS Humber Health Partnership
Enforce maximum stays of 24 hours in AMU and 12 hours in the Emergency Department to maintain patient flow.
View source
NHS Humber Health Partnership
Monitor ambulance arrivals and Emergency Department capacity in real time and escalate boarding or discharge issues through clinical and senior leadership.
View source
NHS England
Continue working with trusts and services facing significant ambulance handover challenges.
View source
NHS England
Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.
View source
NHS England
Prioritise reducing delays in urgent and emergency care pathways.
View source
NHS England
Prioritise improving length of stay in NHS-commissioned community beds.
View source See 12 more actions
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AI-generated summary
Colin Wiles · 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
Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
Wider context from the report “(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances .
” Source location Colin Wiles · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the phased 045 Handover Plan to reduce ambulance handover times toward a 45-minute target.
Verbatim wording from the response “On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Activate the Ambulance Delay Protocol, including site escalation, rapid patient transfers, and prioritisation of suitable patients.
Verbatim wording from the response “1. Ambulance Delay Protocol Activation:
The Ambulance Delay Protocol mandates that ambulance patients should be handed over within 15 minutes of arrival, with no patient waiting longer than 60 minutes. If a delay exceeds 45 minutes with no immediate plan to hand over, the protocol is triggered, requiring:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the operating procedure to offload up to eight ambulances hourly and transfer ten patients from the Emergency Department to inpatient wards.
Verbatim wording from the response “3. Proactive Patient Flow Management:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Pull for Safety to maintain regular patient flow from the Emergency Department to assessment areas and wards.
Verbatim wording from the response “• Implementing the Pull for Safety process, which establishes a regular patient flow from the ED to assessment areas and wards.” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use escalation areas and reverse boarding protocols to create immediate capacity for arriving patients.
Verbatim wording from the response “• Utilising escalation areas and reverse boarding protocols to create immediate capacity for new arrivals, as detailed in the policy.” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Temporary Escalation Space and Boarding SOP to manage capacity challenges, patient boarding, and timely Emergency Department handovers.
Verbatim wording from the response “Between March and April 2023, 20–25% of the Trust's bed base (approximately 180 beds, equivalent to six wards) was occupied by NCTR patients on discharge pathways 1–3. This occupancy severely impacted patient flow and the availability of beds for incoming ED patients. In response, the Trust has undertaken a series of strategic measures to alleviate these pressures. In November 2024 the Trust implemented the Temporary Escalation Space (TES) and Boarding SOP, which provides a framework for managing capacity challenges and improving flow.” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Open and operate a 54-bed NCTR unit to accommodate patients awaiting discharge and reduce reliance on acute beds.
Verbatim wording from the response “1. Creation of Additional Capacity:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement updated discharge protocols covering local-authority coordination, family and carer involvement, and care transfer hubs.
Verbatim wording from the response “2. Formal Discharge and Flow Improvements:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct board rounds and huddles to identify discharges early and meet ward discharge targets of 30% by noon and 70% by 17:00.
Verbatim wording from the response “• Boarding Protocols: The SOP outlines structured boarding processes to manage NCTR patients effectively and create capacity in the ED. This includes:
- Identifying and moving up to three patients per ward to temporary escalation spaces (TES) or discharge lounges within 30 minutes.
- Ensuring timely handovers from ED to inpatient wards to free up ED spaces.” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforce maximum stays of 24 hours in AMU and 12 hours in the Emergency Department to maintain patient flow.
Verbatim wording from the response “3. Operational Measures from the TES and Boarding SOP:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor ambulance arrivals and Emergency Department capacity in real time and escalate boarding or discharge issues through clinical and senior leadership.
Verbatim wording from the response “4. Senior Oversight and Escalation:” Source location Response from NHS Humber Health Partnership
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with trusts and services facing significant ambulance handover challenges.
Verbatim wording from the response “the community. NHS England are continuing to work with trusts and services with significant handover challenges at the ‘front end’, alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient flow and allow new patients to be handed over more promptly to EDs.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise reducing delays in urgent and emergency care pathways.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prioritise improving length of stay in NHS-commissioned community beds.
Verbatim wording from the response “NHS England will also be prioritising:” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local and system concerns fall outside NHS England’s national policy and programme remit.
Verbatim wording from the response “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.” Source location Response from NHS England
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local organisations should address the local and system concerns raised in the report.
Verbatim wording from the response “My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.” Source location Response from NHS England
Open published response
6 Sep 2024 John Francis HOWLETT · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Francis HOWLETT · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.
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× 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 move patients from emergency departments onto wards in a timely manner due to capacity constraints
Wider context from the report “1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues . The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time .
” Source location John Francis HOWLETT · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.
Verbatim wording from the response “We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.
Verbatim wording from the response “We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
Open published response
Concerns raised 1
Delays in moving patients from the ED after a decision that they are ready to discharge View source
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AI-generated summary
Colonel John Frederick Codd · 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
Colonel John Frederick Codd fell while exiting a taxi after a GP appointment and was taken by ambulance to hospital, where he waited outside for approximately 4 hours and 40 minutes before being admitted to the Emergency Department. He was later found in cardiac arrest and could not be resuscitated; the inquest recorded the cause of death as a massive rectus sheath haematoma and severe coronary artery atherosclerosis. The principal concerns were delays in hospital admission and ongoing Emergency Department crowding, which had the potential to affect future patient care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in moving patients from the ED after a decision that they are ready to discharge
Wider context from the report “1) At the time of these events, (January 2024) monthly crowding analysis, that is the total amount of time patients spent waiting for beds or transport after a decision ‘ready to discharge’ from ED was made totalled 23,875 hours , the equivalent of closing 32 cubicles to ED for 24 hours/day for a whole month.
2) Last month, in June 2024, the situation had improved but still totalled 16,245 hours of lost time , the equivalent of closing 22 cubicles for an entire month.
████████ was clear in his evidence that significant pressures remained on the ED at Royal Cornwall Hospital which had the potential to affect future patient care .
” Source location Colonel John Frederick Codd · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Return to safe operational waiting-time standards set out in the NHS Constitution.
Verbatim wording from the response “At a national level, this government is committed to returning to the safe operational waiting time standards set out in the NHS Constitution. In doing so we will be honest about the challenges facing the health service and serious about tackling them. The Health Secretary ordered an independent investigation of NHS performance to provide an assessment of the issues and challenges it faces. This report on 12th September 2024 and the investigation’s findings will feed into the government’s work on a 10-year plan to radically reform the NHS and build a health service that is fit for the future.” Source location Response from DHSC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop local NHS-social care partnerships to reduce delayed discharges and prevent hospital departments being blocked.
Verbatim wording from the response “Regarding the concern raised about discharge delays, 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.