Recurring concern

Failure to maintain safe hospital patient flow

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First reported 19 Feb 2015•Latest report 18 Jun 2026

Definition

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.

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: 33
Individual concerns: 37
Date range: 2015–2026
Stated actions: 115

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care15

Welsh Ambulance Services NHS Trust9

Betsi Cadwaladr University LHB7

Ysbyty Gwynedd3

Care Quality Commission2

NHS England2

Aneurin Bevan University LHB1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Conwy County Borough Council1

Denbighshire County Council1

East Midlands Ambulance Service NHS Trust1

East Riding of Yorkshire Council1

Flintshire County Council1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Concerns and responses across reports

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

6 Jan2022
Norfolk
Concerns raised1
1. Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 15
1. Action
  Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
2. Action
  Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
3. Action
  Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
1. Action
  Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
2. Action
  Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
3. Action
  Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
4. Action
  Deliver the Leading for System Change project to identify and address system-wide discharge barriers.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
5. Action
  Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
6. Action
  Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated in progress
7. Action
  Deliver six new ambulance hubs to reduce handover delays.
  Stated by Department of Health and Social CareStated in progress
8. Action
  Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.
  Stated by Department of Health and Social CareStated in progress
9. Action
  Provide 5,000 additional staffed permanent hospital beds.
  Stated by Department of Health and Social CareStated planned
10. Action
  Scale up virtual ward capacity beyond its existing level.
  Stated by Department of Health and Social CareStated planned
11. Action
  Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.
  Stated by Department of Health and Social CareStated in progress
12. Action
  Establish Same Day Emergency Care services across every hospital with a major emergency department.
  Stated by Department of Health and Social CareStated planned
Respondent positions 3
1. Position
  The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
1. Position
  Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
2. Position
  Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardUnable to act
AI-generated summary

Kyriacos Athanasis · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain emergency department and inpatient capacity for timely ambulance admissions
Wider context from the report
“(4) The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave. The staff at the Trust indicated that they did not consider that locally there were any further steps they could take and gave evidence this was a more complex problem, predominately due to the Trust’s inability to discharge patients who are medically fit to be discharged and occupying much needed beds. This in turn means that they are unable to move patients from the emergency department to beds in the hospital in a timely manner which leads to them not having capacity to admit patients brought in by ambulances. This clearly means that ambulances are delayed and in turn are unable to attend other emergencies in a timely manner. ”
Source location
Kyriacos Athanasis · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Support further development and expansion of GP Streaming Units across the three acute hospitals to improve patient flow and prompt assessment.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand Same Day Emergency Care provision across acute hospital sites as an alternative pathway to Emergency Department attendance.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Coordinate the system Discharge Programme, including joint planning, delivery and monitoring of hospital-flow and discharge improvements.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Commission additional health and social care beds, community care packages and domiciliary care to increase discharge capacity.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Fund additional social workers and use external agencies to provide Care Act assessments and domiciliary care supporting discharge home.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver the Leading for System Change project to identify and address system-wide discharge barriers.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Coordinate local improvement, escalation and monitoring programmes covering ambulance alternatives, falls response, Emergency Department surge, care homes, workforce and discharge.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a virtual ward across the three acute hospitals to support early discharge and avoid Emergency Department attendance.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 7 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver six new ambulance hubs to reduce handover delays.

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.

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

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide 5,000 additional staffed permanent hospital beds.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Scale up virtual ward capacity beyond its existing level.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish Same Day Emergency Care services across every hospital with a major emergency department.

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

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The rapid-release protocol can only be mobilised in specific clinical circumstances, limiting its use to reduce ambulance handover delays.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 3 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Discharge capacity was constrained after national funding ended and the ICB’s temporary local funding extension ceased.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 4 · response
Published 9 January 2023
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Safe discharge depends fundamentally on adequate social care provision, limiting the system’s ability to relieve hospital congestion independently.

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

Source location
Response from Norfolk and Waveney Integrated Care Board
Page 5 · response
Published 9 January 2023
Open published response
9 Sep2020
Gwent
Concerns raised1
1. Delays in transferring patients into hospital care, preventing emergency ambulance release
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Alyn Rees · 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

Alyn Rees became acutely unwell on 3 December 2019, experienced breathing difficulties, deteriorated into cardiac arrest, and died after paramedics were unable to revive him. Concerns were raised about the approximately two-hour wait for an emergency ambulance, the lack of advice about the expected arrival time, the absence of an indicated response time for an Amber 1 call, and delays transferring patients into hospital care that prevented ambulances from being released.

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 transferring patients into hospital care, preventing emergency ambulance release
Wider context from the report
“However, the family raised concerns, with which I agreed, that 2 hours is a long time to wait for an emergency ambulance. At no time were the family advised of the expected time of arrival and potentially, if they had been aware of this, they may have contacted earlier the local GP. The report did not indicate what the expected response time for an Amber 1 call should be. I was advised that on this occasion there were significant delays (up to 3 hours) transferring patients into the care of Aneurin Bevan University Health Board Hospitals. This is also of significant concern as it prevented emergency ambulances being released. ”
Source location
Alyn Rees · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Jan2020
Manchester West
Concerns raised1
1. Failure to prioritise new admissions and maintain patient flow through the ward
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Daniel Jeffrey Moran · 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

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

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 prioritise new admissions and maintain patient flow through the ward
Wider context from the report
“2. Ward staff needed to have a greater understanding of how to prioritise new admissions and ensure the better flow of patients through the ward ”
Source location
Daniel Jeffrey Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Sep2018
North Wales (East and Central)
Concerns raised1
1. Failure of patient flow processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Gladys May Williams · 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

Gladys May Williams fell at her care home on 6 March 2018, was discharged from hospital, deteriorated, and experienced delays in ambulance response and handover on 7 March. The report raises continuing concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that patients’ lives may be at risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of patient flow processes
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems appear to be continuing notwithstanding the various measures which I am informed have been and are continuing to be put in place by WAST and BCUHB to mitigate such problems and I continue to believe and be extremely concerned that patients’ lives are being placed at risk as a result. Whilst it no longer appears to be the case that problems of this nature can be attributed to “winter pressures” it is nonetheless of grave concern that we are approaching another winter period without any clear indication that progress is being made to improve upon the previous position. ”
Source location
Gladys May Williams · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Jun2018
North Wales (East and Central)
Concerns raised1
1. Failures in patient flow
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Margaret Megan Evans · Prevention of Future Deaths report

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

Report summary

Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.

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
Failures in patient flow
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result. ”
Source location
Margaret Megan Evans · Prevention of Future Deaths report
Page 1 · concerns
Open source report
6 Jun2018
North Wales (East and Central)
Concerns raised1
1. Failure to maintain safe patient flow
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Ester Jane Wood · 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

Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain safe patient flow
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”
Source location
Ester Jane Wood · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Jul2017
North Wales (East and Central)
Concerns raised1
1. Failure to maintain effective patient flow
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Catherine Haf Roberts · Prevention of Future Deaths report

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

Report summary

Catherine Haf Roberts arrived at hospital by ambulance after becoming unwell with persistent diarrhoea and waited outside before remaining in the emergency department for 58 hours because of capacity and ward-space constraints. Her condition deteriorated after transfer to a medical ward, and she died in hospital on 11 February 2016. The principal concern was the continuing lack of an agreed and effective system plan addressing emergency department admission, resource availability and patient flow, which the report states was placing patients’ lives at risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain effective patient flow
Wider context from the report
“The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests. Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place. ”
Source location
Catherine Haf Roberts · Prevention of Future Deaths report
Page 1 · concerns
Open source report
25 May2017
North Wales (East and Central)
Concerns raised1
1. Failure of patient flow processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
3. Action
  Increase specialty medical and surgical in-reach to assess ED patients before inpatient admission.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
1. Action
  Establish a Night Sister post to support clinical site management, patient flow, quality, and safety.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
2. Action
  Open additional surge inpatient bed capacity during peak demand when staffing permits safe operation.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
3. Action
  Operate a Step Down Manager role coordinating transfers of patients with complex care needs to appropriate next-stage services.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
4. Action
  Staff additional holding areas away from ED during extreme pressure to support patient flow.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
5. Action
  Implement the SAFER patient-flow bundle across all three acute hospital sites, supported by senior clinical leadership and communications.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
6. Action
  Conduct daily discharge-focused board rounds and weekly reviews of delayed transfers of care at both hospital sites.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
Respondent positions 1
1. Position
  Establishing a North Wales Bed Bureau was not considered feasible for improving acute hospital access because of geography and local-admission priorities.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustUnable to act
AI-generated summary

Daphne Edith Williams · 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

Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her 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
Failure of patient flow processes
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result. ”
Source location
Daphne Edith Williams · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.

Verbatim wording from the response
“At Ysbyty Maelor Wrecsam, a holding area in ED is created whenever possible during the day to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical ‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.”

Source location
2017-0167-Response-by-University-Health-Board
Page 6 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.

Verbatim wording from the response
“• A review of the use of the physical space within ED has created an open ambulatory chair centric area with 4 additional assessment/treatment spaces; the commissioning of 2 additional beds in the observation bedded area of the ED; the use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am - 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure.”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase specialty medical and surgical in-reach to assess ED patients before inpatient admission.

Verbatim wording from the response
“• Work is also on-going to increase specialty ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a Night Sister post to support clinical site management, patient flow, quality, and safety.

Verbatim wording from the response
“• A Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues”

Source location
2017-0167-Response-by-University-Health-Board
Page 8 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Open additional surge inpatient bed capacity during peak demand when staffing permits safe operation.

Verbatim wording from the response
“• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely.”

Source location
2017-0167-Response-by-University-Health-Board
Page 8 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate a Step Down Manager role coordinating transfers of patients with complex care needs to appropriate next-stage services.

Verbatim wording from the response
“• A ‘Step Down’ Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay (this may be: placement in a nursing/residential home, transfer to a community hospital or back to their own homes with packages of support). However local”

Source location
2017-0167-Response-by-University-Health-Board
Page 8 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Staff additional holding areas away from ED during extreme pressure to support patient flow.

Verbatim wording from the response
“• In times of extreme pressure, additional holding areas are staffed away from ED to assist with the pull through of patients from ED to sustain flow of emergency patients.”

Source location
2017-0167-Response-by-University-Health-Board
Page 9 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the SAFER patient-flow bundle across all three acute hospital sites, supported by senior clinical leadership and communications.

Verbatim wording from the response
“4.3. SAFER BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months. This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are:”

Source location
2017-0167-Response-by-University-Health-Board
Page 9 · response
Published 31 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct daily discharge-focused board rounds and weekly reviews of delayed transfers of care at both hospital sites.

Verbatim wording from the response
“5. Improvement in the discharge/transfer of care of patients at the end of their acute hospital stay. As well as the actions outlined above, BCUHB works collaboratively with WAST and Local Authorities to support the safe discharge/transfer of care of patients following their acute hospital stay to ensure patients don’t remain in hospital longer than they require. At both Ysbyty Maelor Wrecsam and Ysbyty Glan Clwyd, there is a strong focus on early identification of patients who are medically fit for discharge to ensure timely discharge. Daily ‘board rounds’ are held across acute adult wards to ensure daily discussion of each patient and their care needs, including discharge planning as appropriate with local authority colleagues. There is a weekly review at both hospital sites of patients experiencing a ‘Delayed Transfers of Care’ (DTOC).”

Source location
2017-0167-Response-by-University-Health-Board
Page 10 · response
Published 31 August 2017
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
Establishing a North Wales Bed Bureau was not considered feasible for improving acute hospital access because of geography and local-admission priorities.

Verbatim wording from the response
“In reviewing the action plans already submitted in response to previous Regulation 28 reports relating to patient flow, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling the admission of emergency patients to as local a hospital as possible, as often as possible.”

Source location
2017-0167-Response-by-University-Health-Board
Page 1 · response
Published 31 August 2017
Open published response
17 May2017
North Wales (East and Central)
Concerns raised1
1. Failure of hospital patient flow and delayed transfer of care processes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 15
1. Action
  Develop enhanced multidisciplinary community resource teams to provide care at home.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
2. Action
  Increase specialty medical and surgical in-reach into ED to support earlier assessment and discharge.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
3. Action
  Create a Night Sister post to support patient flow and safety at Ysbyty Maelor Wrexham.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
1. Action
  Trial Frailty Assessment Units to support front-door assessment and admission avoidance.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated planned
2. Action
  Open additional surge inpatient capacity during peak demand where staffing permits safe operation.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
3. Action
  Create a Step Down Manager post to coordinate movement of complex-care patients through discharge pathways.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
4. Action
  Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit patients from ED and primary care without undue delay.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
5. Action
  Provide overnight district nursing in Wrexham to support safe care at home.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
6. Action
  Develop the IV suite to provide emergency and elective IV therapy without overnight admission.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
7. Action
  Implement the SAFER patient-flow bundle across all three acute hospital sites.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
8. Action
  Develop patient-transfer, discharge, routine and repatriation guidance for ambulance-resource requests.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
9. Action
  Provide dedicated hospital social-work staffing and rapid reablement support for discharge in Flintshire.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
10. Action
  Invest in integrated generic health and social-care support staff to assist hospital discharges in Wrexham.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
11. Action
  Establish five short-term extra-care apartments to support admission avoidance and timely discharge in Conwy.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
12. Action
  Establish a joint Single Point of Access and step-down cluster to support hospital discharge in Denbighshire.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
AI-generated summary

Lilly Baxandall · Prevention of Future Deaths report

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

Report summary

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

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop enhanced multidisciplinary community resource teams to provide care at home.

Verbatim wording from the response
“• Developing enhanced multi-disciplinary community resource teams (CRT) to provide more care for individuals in their own homes. The CRTs are in varying degrees of development across North Wales and whilst have the potential to better manage care closer at home need to build on the range of successful intermediate care provision already delivered in the 6 local authorities.”

Source location
2017-0160-Response-by-University-Health-Board
Page 5 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase specialty medical and surgical in-reach into ED to support earlier assessment and discharge.

Verbatim wording from the response
“• Work is also on-going to increase speciality ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.”

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Create a Night Sister post to support patient flow and safety at Ysbyty Maelor Wrexham.

Verbatim wording from the response
“• A Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Trial Frailty Assessment Units to support front-door assessment and admission avoidance.

Verbatim wording from the response
“• In early autumn, a Frailty Assessment Unit will be trialled, providing a more comprehensive assessment of frail patients at the ‘front door’ with the aim of avoiding admission for some of these by providing additional community support to enable patients to be safely managed in their own homes. This needs further discussion with the local authorities.”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Open additional surge inpatient capacity during peak demand where staffing permits safe operation.

Verbatim wording from the response
“• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely.”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Create a Step Down Manager post to coordinate movement of complex-care patients through discharge pathways.

Verbatim wording from the response
“• A ‘Step Down’ Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit patients from ED and primary care without undue delay.

Verbatim wording from the response
“• From the 1st August 2017, a rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with a Frailty Assessment Unit with a focus on admission avoidance to return individuals to their own homes with the support of community staff, including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours. Patients will be treated as ambulatory until proven otherwise and within the unit, individuals will receive rapid diagnosis and stabilisation before they are supported home.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide overnight district nursing in Wrexham to support safe care at home.

Verbatim wording from the response
“• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the escalation of additional beds on some wards where staffing levels enable this to be done safely. The District Nursing Service in Wrexham is now available overnight, enabling more patients to be safely cared for at home rather than remain in hospital.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop the IV suite to provide emergency and elective IV therapy without overnight admission.

Verbatim wording from the response
“• The provision of an IV suite continues to develop as an important service to enable individuals to receive IV therapy as a day attender (both emergency and elective) without the need for an overnight hospital stay.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the SAFER patient-flow bundle across all three acute hospital sites.

Verbatim wording from the response
“4.3. SAFER BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months. This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are:”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop patient-transfer, discharge, routine and repatriation guidance for ambulance-resource requests.

Verbatim wording from the response
“Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process. WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation Guidance’ to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their discharge/transfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls.”

Source location
2017-0160-Response-by-University-Health-Board
Page 10 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide dedicated hospital social-work staffing and rapid reablement support for discharge in Flintshire.

Verbatim wording from the response
“Flintshire has community based, responsive Community Care services which work effectively to prevent people being admitted to hospital when it is feasible and safe for these people to be supported at home. We have a leading Reablement Service which intervenes effectively, often on the same day and certainly with due urgency to ensure people maintain their independence, do not deteriorate and are supported at home. We also have a fully functioning Single Point of Access with involvement of the Voluntary Sector and co-located with Health. Finally, Flintshire leads on behalf of Wrexham, BCUHB and our County with a Community Equipment Service which provides rapid and responsive equipment again if needed, on the same day. There are 10 dedicated hospital social workers to facilitate discharge as soon as an individual is medically fit to leave the acute hospital.”

Source location
2017-0160-Response-by-University-Health-Board
Page 11 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Invest in integrated generic health and social-care support staff to assist hospital discharges in Wrexham.

Verbatim wording from the response
“Provision of dedicated hospital social workers and Assistant Team Manager to facilitate discharge as soon as an individual is medically fit to leave the acute hospital. The social workers are based at the Maelor Hospital and Chirk community hospital and are integrated with the Discharge Liaison team.”

Source location
2017-0160-Response-by-University-Health-Board
Page 12 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish five short-term extra-care apartments to support admission avoidance and timely discharge in Conwy.

Verbatim wording from the response
“Conwy have established 5 successful short term apartments at our Extra Care Housing Schemes. These apartments provide individuals with their own flat and an on-site support teams focused on Reablement and retaining independence. This supports individuals to either avoid a hospital admission or facilitate discharge to an intermediate facility before (primarily) returning home. These beds have further strengthened our ability to offer appropriate and timely discharge for people who are medically fit to leave inpatient beds but are not yet ready to go home.”

Source location
2017-0160-Response-by-University-Health-Board
Page 13 · response
Published 17 August 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Establish a joint Single Point of Access and step-down cluster to support hospital discharge in Denbighshire.

Verbatim wording from the response
“This has resulted in a number of changes to how services have been provided in the past and include a joint Single Point of Access with agreed pathways for discharge from hospital and a co-located Community Team of health and social care professionals able to work together more effectively. The latter will be rolled out across the County when its effectiveness has been reviewed.”

Source location
2017-0160-Response-by-University-Health-Board
Page 14 · response
Published 17 August 2017
Open published response
14 Mar2017
North Wales (East and Central)
Concerns raised1
1. Patient flow failing to enable admission of patients requiring treatment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Increase emergency-department capacity by opening additional minor-attendance rooms and converting trolley space into a four-chair ambulatory area.
  Stated by Betsi Cadwaladr University LHBStated completed
1. Action
  Strengthen out-of-hours site management through twilight managers, a new clinical rota, additional night sisters and a senior manager role.
  Stated by Betsi Cadwaladr University LHBStated in progress
2. Action
  Develop a revised Bronze and Silver on-call model with dedicated 24-hour Silver cover, clinical support and strengthened site-management resilience.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Develop surge-capacity arrangements for peak evening and overnight demand using previously unstaffed clinical space.
  Stated by Betsi Cadwaladr University LHBStated completed
4. Action
  Use medical-fit-for-discharge data to develop escalation pathways and teams, including the YGC Step Down Team, for alternative discharge or transfer options.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Rebecca Anne Evans · 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

Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and ambulance availability.

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
Patient flow failing to enable admission of patients requiring treatment
Wider context from the report
“3. It is of grave concern to me that my statutory duty requires me to report these concerns by way of regulation 28 reports on a very regular basis and that despite previous such reports there continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment. ”
Source location
Rebecca Anne Evans · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.

Verbatim wording from the response
“Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached. The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target.”

Source location
2017-0077-Response-by-University-Health-Board
Page 1 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.

Verbatim wording from the response
“The use of information within Unscheduled Care decision making There is extensive use of predictive tools and modeling within our overall approach to Unscheduled Care. The overall capacity and demand model developed by the planning section has informed the scale of improvement required to achieve a bed occupancy level of 85%. The metrics within the overall plan are calibrated at a level which has been calculated to enable the 4 hour target to be achieved and improve ambulance handover.”

Source location
2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Increase emergency-department capacity by opening additional minor-attendance rooms and converting trolley space into a four-chair ambulatory area.

Verbatim wording from the response
“6. Emergency department Capacity; both EDs have reviewed the demand profiles and commissioned additional clinical capacity. WMH have opened two additional examination rooms for minor attendances to protect the minors stream. YGC have converted one minors trolley space to a four chair ambulatory area to increase minors stream capacity.”

Source location
2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen out-of-hours site management through twilight managers, a new clinical rota, additional night sisters and a senior manager role.

Verbatim wording from the response
“7. Operational site management; WMH have employed twilight site managers to support evening bed pressures. All three acute hospitals in the Health Board are moving towards a new out of hours site management clinical rota to support flow and response to escalation. This includes additional night sisters to support core site management. WMH also provide a Senior Manager of the day who works till 8pm to support decompression of acute problems affecting flow.”

Source location
2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a revised Bronze and Silver on-call model with dedicated 24-hour Silver cover, clinical support and strengthened site-management resilience.

Verbatim wording from the response
“10. Senior Manager Bronze and Silver on call arrangements; a formal review of Bronze and Silver on call manager rotas in recognition of the demands of unscheduled care pressures has informed the development of a new model. This includes”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop surge-capacity arrangements for peak evening and overnight demand using previously unstaffed clinical space.

Verbatim wording from the response
“11. Evening / Overnight Capacity; all sites have developed surge capacity options to meet periods of peak demand during the evening and overnight. This utilizes physical capacity that would not normally be staffed overnight, therefore increasing capacity and utilization of core clinical estate.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use medical-fit-for-discharge data to develop escalation pathways and teams, including the YGC Step Down Team, for alternative discharge or transfer options.

Verbatim wording from the response
“12. Development of Medical Fit to Discharge data; WMH and YGC have used data extracted specifically from WPAS and local data collection to identify patients fit for discharge but delayed due to factors outside of the acute hospital control. This has resulted in the development of new escalation pathways and teams, such as the Step Down Team at YGC to secure alternative discharge / transfers options for MFDs contributing to bed blockages and bed turn over.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

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

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.15

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

Concerns raised1

Delays in transferring patients into hospital care, preventing emergency ambulance release

Concerns raised1

Failure to prioritise new admissions and maintain patient flow through the ward

Concerns raised1

Failure of patient flow processes

Concerns raised1

Failures in patient flow

Concerns raised1

Failure to maintain safe patient flow

Concerns raised1

Failure to maintain effective patient flow

Concerns raised1

Failure of patient flow processes

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

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

Actions described in response 15

Respondent positions 3

Actions described in response 9

Respondent positions 1