Recurring concern

Failure to maintain safe hospital patient flow

First to latest report 19 Feb 2015 — 18 Jun 2026

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

What this concern includes

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

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

Reports and published responses 33 reports

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

  1. East London

    AI-generated summary

    Mrs Anna Teresa Walker · 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

    Mrs Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.

    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

    Chaotic transfer pathway for radiology patients to the ward

    Wider context from the report

    “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust. II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure). III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring. ”

    Source location

    Mrs Anna Teresa Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. North Wales (East and Central)

    AI-generated summary

    Pamela June Conway · 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

    Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of patient flow within the Maelor Hospital causing delays in the Emergency Department

    Wider context from the report

    “2. Evidence at the inquest indicated that the problem of “patient flow” within the Maelor Hospital continues to result in delays within the Emergency Department and it is of considerable concern to me that such problems have been the subject of previous regulation 28 reports and are also within the scope of a number of ongoing inquests. ”

    Source location

    Pamela June Conway · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Elizabeth Muriel Leah · 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

    Elizabeth Muriel Leah, an 87-year-old care home resident with severe dementia, fell on 2 July 2014 and broke her femur. Although an ambulance was called, staff were advised to take her to hospital by taxi because of an anticipated ambulance delay. The principal concerns were insufficient ambulance and staffing capacity, delays transferring patients into emergency departments, and hospital bed-blocking.

    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 getting patients into A and E departments

    Wider context from the report

    “On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi. This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi. When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time. This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems. These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government. ”

    Source location

    Elizabeth Muriel Leah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

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Data last updated 7 September 2026