Concerns raised 1
Failure to complete ambulance handovers within 15 minutes of arrival at the emergency department 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
ROBERT ANDREW PROWSE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.
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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 Failure to complete ambulance handovers within 15 minutes of arrival at the emergency department
Wider context from the report “12. The build-up of patients in the emergency department leads to handover delays between ambulance and hospital, namely ambulance crews being unable to transfer patients from ambulances into the emergency department . It was found that there is a strong correlation between ambulance handover delays and increasing ambulance response times. The investigation report stated:
‘It is as simple as the longer a patient is waiting in an ambulance outside a hospital, the longer the next patient will wait for an ambulance’.
13. The investigation report states
‘…SWAST is experiencing by far the highest levels of handover delays seen in the Trust’s history. Handover delays result in multiple ambulance resources being held at hospitals for extended periods, thereby limiting the number of resources on the road to respond to waiting incidents . With fewer resources on the road, the response times to patients inevitably increases…
….The impact of the delays …is devastating, most significant, and most immediately evident to patients and their families and carers. Less evident is the secondary, detrimental effect these delays can bring to the service as a whole. This investigation found that delays are having an additional profound impact on staff morale and their mental wellbeing.’
14. The court considered SWAST performance data for 2023 in connection with handover delays between ambulances and hospitals. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. Anything above this constitutes a delay which impacts on the availability of resources. The data revealed that in September 2023, handover delays (in excess of 15 minutes), cost the ambulance service 2,981 hours at Treliske. This is equivalent to 271 ambulance crew shifts. At Derriford in the same month, handover delays (in excess of 15 minutes) cost the ambulance service 6,359 hours, which is equivalent to 581 ambulance crew shifts.
15. The court considered data for 2023 showing total operational resource hours lost to handover delays in excess of 15 minutes. The total lost by SWAST at Treliske was 35,583 hours. At Derriford the total lost in 2023 was 53,080 hours.
” Source location ROBERT ANDREW PROWSE · 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 Invest an additional £1 billion through the Discharge Fund to support timely and effective hospital discharge.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
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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 Ensure every acute hospital has access to a care transfer hub supporting complex discharges and early planning.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
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 SWAST and RCHT are best placed to determine and implement local action to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “You have appropriately shared your report and concerns with SWAST and Royal Cornwall Hospital Trust (RCHT), who are best placed to respond on the specific action they are taking locally to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in offloading patients at hospitals tying up ambulance resources 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
Jean 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
Jean WALKER became unwell at home on 4 November 2022 and was struggling to breathe when her daughter called 999 at 0348. She died before the ambulance arrived at 0542 and was pronounced dead at 0551. The principal concerns were the delayed ambulance response and hospital offloading delays that reduced available ambulance resources; the inquest concluded that the delay resulted in a missed opportunity to provide medical assistance, although it could not be said that earlier intervention would have prevented her death.
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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 offloading patients at hospitals tying up ambulance resources
Wider context from the report “(2) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls .
” Source location Jean WALKER · 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 Provide additional funding to expand ambulance capacity and increase staffed hospital beds.
Verbatim wording from the response “Your report highlights reduced ambulance resource in the Yorkshire region at the time of the incident. To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from DHSC
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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 Participate with YAS and regional ICBs in joint priority-setting, performance improvement and additional investment allocation.
Verbatim wording from the response “Since April 2023, the three Integrated Care Boards (ICBs) across Yorkshire and Humber have worked jointly through an Executive Leadership Board (ELB) with YAS to agree joint priorities and to improve performance and allocate additional investment. This investment was aimed at recruiting additional ambulance crews, developing new ways of working to avoid conveyance to hospital, and investment in new vehicles, all of which are aimed at being able to provide a more timely response and meet increasing demand.” Source location Response from West Yorkshire ICB
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation West Yorkshire Integrated Care Board will respond on the specific local actions being taken to support ambulance response times.
Verbatim wording from the response “Your report raised concerns about ambulance response times and capacity at Yorkshire Ambulance Service NHS Trust (YAS) as a result of handover delays at hospitals. These concerns were also raised directly with the responsible NHS Integrated Care Board.” Source location Response from DHSC
Open published response
Concerns raised 1
Delays in offloading patients into hospital 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
Jean Thomas · 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
Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.
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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 offloading patients into hospital
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie. I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be offloaded into hospital . The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes ,
” Source location Jean Thomas · 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 Work with the Welsh Ambulance Service to develop use of pressure-relieving equipment during ambulance transport and delayed handover situations.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
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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 Apply a zero-tolerance threshold to ambulance off-load delays exceeding 10 hours as part of improving handover times.
Verbatim wording from the response “In November 2023, a “zero” tolerance to ambulance off-load delays, in excess of 10 hours, was introduced, at Morriston Hospital. The introduction of this tolerance is part of a reduction trajectory to improving handover times and achieving the 15-minute target. However, despite improvements in this area, continued pressures on the unscheduled care system has resulted in delays over 10 hours still being experienced by patients.” Source location Response from Swansea Bay University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing plans, resource measures and organisational monitoring are considered sufficient, so no further action is proposed on ambulance and hospital delays.
Verbatim wording from the response “Firstly at this time, the Trust does not propose to take any further action or new actions in relation to the matter of ambulance delays in arriving with patients and patients delayed outside of hospitals. The Trust is taking all possible steps within its control to ensure availability of appropriate resources.” Source location Response from Welsh Ambulance Services NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation REACT assessments largely prevent significant harm during delayed ambulance handovers by identifying patient risks and enabling immediate treatment or prevention.
Verbatim wording from the response “The majority of delayed ambulance handover events do not result in a significant harm to a patient. This is largely due to the REACT risk assessment described above. In the rare case when a patient does incur a significant harm, a Duty of Candour process is triggered; notified to the patient and/or family and a full investigation undertaken with the outcome provided in line with “Putting Things Right” (2011) Regulations.” Source location Response from Swansea Bay University Health Board
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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 Use of pressure-relieving ambulance equipment depends on the Welsh Ambulance Service accepting the Health Board’s existing offer of equipment.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
Open published response
22 Feb 2024 Joseph Leonard Scott Cattle · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Delays in hospital handover holding up ambulance resources View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Welsh Government
Direct each Local Health Board to develop a local Six Goals plan incorporating ambulance handover and patient-flow improvements.
View source
Welsh Government
Implement the Pathways of Care Delays Reporting Framework to provide regional data for targeting discharge interventions.
View source
Welsh Government
Issue guidance setting expectations and targets for timely ambulance handover, including required actions when handover exceeds 60 minutes.
View source
Welsh Government
Monitor and scrutinise Local Health Board and ambulance-service performance against ambulance handover targets through regular assurance meetings and escalation arrangements.
View source See 1 more action
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AI-generated summary
Joseph Leonard Scott Cattle · 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
Joseph Leonard Scott Cattle contacted the Welsh Ambulance Service Trust at 00:44 in a call categorised as requiring an Amber 1 response, followed by two further calls. Paramedics did not attend until approximately 07:20, by which time he was deceased; concerns included the delay in allocating an ambulance, hospital handover delays affecting ambulance availability, and an apparent shortfall in funded ambulances.
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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 hospital handover holding up ambulance resources
Wider context from the report “(2) Despite having their full complement of ambulance resources staffed and on shift many
of them were held up by delays in handover at hospitals ;
” Source location Joseph Leonard Scott Cattle · 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 Direct each Local Health Board to develop a local Six Goals plan incorporating ambulance handover and patient-flow improvements.
Verbatim wording from the response “I have directed each LHB to develop a local ‘six goals’ programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. This programme plan forms a key part of LHBs’ broader Integrated Medium-Term Plans (IMTPs).” Source location Response from Welsh Government
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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 Implement the Pathways of Care Delays Reporting Framework to provide regional data for targeting discharge interventions.
Verbatim wording from the response “To ensure we have accurate data on delayed discharges, the Pathways of Care Delays (PoCD) Reporting Framework has been implemented. This is a formal reporting mechanism that provides health and social care partners with a comprehensive and vital overview of their regional discharge delays so that relevant interventions and actions can be targeted more appropriately.” Source location Response from Welsh Government
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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 Issue guidance setting expectations and targets for timely ambulance handover, including required actions when handover exceeds 60 minutes.
Verbatim wording from the response “A Welsh Health Circular (“WHC”) was issued in 2016, setting out expectations of LHBs and partners to deliver timely ambulance patient handover through consistent delivery of a range of actions for both pre and post arrival such as: communication, alternative pathways, staffing levels, and booking in processes. It is the expectation of the Welsh Government that these actions are done consistently to meet handover targets.” Source location Response from Welsh Government
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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 and scrutinise Local Health Board and ambulance-service performance against ambulance handover targets through regular assurance meetings and escalation arrangements.
Verbatim wording from the response “In practice, the Welsh Government monitors the performance of NHS Wales bodies in several different ways. In relation to the monitoring of ambulance patient handovers to emergency departments, a number of specific measures have been put in place in order to ensure the Welsh Government can assess how LHBs and WAST are performing.” Source location Response from Welsh Government
Open published response
Concerns raised 1
Delays in offloading ambulance patients at hospitals View source
This report raised 3 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
Shaun PARKS · 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
Shaun PARKS attended Doncaster Royal Infirmary with a heart attack and waited for an ambulance transfer to the Northern General Hospital. He deteriorated and died during a procedure on 13 December 2022. Concerns included a 3-hour 18-minute ambulance response delay, insufficient emergency dispatch staffing, and hospital delays in offloading patients that reduced ambulance availability.
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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 offloading ambulance patients at hospitals
Wider context from the report “(3) There was a significant delay in offloading patients at hospitals , which tied up resources and meant they were unable to respond to emergency calls.
” Source location Shaun PARKS · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to admit ambulance patients promptly and return ambulances to active duty View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB Welsh Government
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Welsh Government
Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
View source
Welsh Government
Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
View source
Welsh Government
Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.
View source
Welsh Government
Implement an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.
View source
Welsh Government
Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.
View source
Welsh Government
Use monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.
View source
Betsi Cadwaladr University LHB
Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
View source See 4 more actions
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Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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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 Failure to admit ambulance patients promptly and return ambulances to active duty
Wider context from the report “9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff , due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty .
” Source location Vivienne Greener · 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 Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
Verbatim wording from the response “To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations of health boards and NHS trusts through an annual NHS planning framework. Organisations are expected to produce integrated medium-term plans annually, that respond to the priorities set in the NHS planning framework. The planning framework clearly sets out my expectation that health boards prioritise plans to improve timeliness of ambulance patient handovers to free up ambulance clinicians to respond to patients in the community. Given the relationship between both timely patient discharge and ambulance patient handover, I have also set a priority for improvement in patient flow.” Source location Response from Welsh Government
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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 Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
Verbatim wording from the response “To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:” Source location Response from Welsh Government
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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 Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.
Verbatim wording from the response “In addition, I directed the Chief Ambulance Services Commissioner to monitor delivery of plans intended to secure improvements through Emergency Ambulance Services Committee governance mechanisms. The Committee, made up of the seven chief executives of health boards, agreed to work towards eradicating all handover delays over four hours in length by the end of 2024/2025.” Source location Response from Welsh Government
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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 Implement an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.
Verbatim wording from the response “In view of my concern, all health board chief executives were directed to prioritise three actions for delivery over the winter months as part of a new NHS Wales ambulance patient handover improvement plan implemented from the festive period 2023/2024. As part of their local plan, the Betsi Cadwaladr University Health Board priority actions include:” Source location Response from Welsh Government
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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 Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.
Verbatim wording from the response “• I hold health board chairs to account for delivery and have incorporated ambulance patient handover improvement as a key objective for all chairs for 2023/2024. I consistently seek assurance from chairs as a collective on their organisations’ commitment to making improvements through regular national meetings.” Source location Response from Welsh Government
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 monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.
Verbatim wording from the response “• There are established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Assurance is sought and challenge provided on a regular basis regarding ambulance patient handover performance, through ‘integrated quality, planning and delivery (IQPD)’ meetings between Welsh Government, the NHS Executive and NHS organisations.” Source location Response from Welsh Government
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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 Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
Verbatim wording from the response “Processes are taking place in respect of patient flow to release capacity, however, we are reviewing the opportunity to create additional capacity in terms of infrastructure changes and a review of our current START clinical area. This would create a dedicated speciality waiting area with cubicles for review. This scoping is work in progress, and will be formalised.” Source location Response from Betso Cadwaladr University Health Board
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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 delivering health services, including ambulance handover improvements, rests with the health board rather than Welsh Ministers.
Verbatim wording from the response “My response will largely focus upon the ninth matter of concern in the report, regarding the timeliness of ambulance patient handover, and the health board will reply on matters of concerns 1 – 8. My officials have worked with the health board to ensure that our responses are co-ordinated and consistent. It is important to ensure lines of accountability are clear given that responsibility for delivery of services falls with the health board. The role of the Welsh Ministers is to set the strategic direction for health boards and NHS trusts and to hold them to account for delivery of policy.” Source location Response from Welsh Government
Open published response
Concerns raised 1
Delays in offloading ambulance patients at hospitals View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
David John Briggs · 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
David John Briggs died at the Northern General Hospital, Sheffield, on 15 November 2022 after developing urosepsis associated with urinary tract obstruction and a long-term catheter. His carers made several emergency calls as his breathing deteriorated, but the ambulance arrived at 0044 after the first call at 2049. Concerns included insufficient ambulance service resources, delays in responding to the Category 2 call, and hospital offloading delays that reduced ambulance availability.
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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 offloading ambulance patients at hospitals
Wider context from the report “(3) There was a significant delay in offloading patients at hospitals which tied up ambulance resource and meant they were unable to respond to emergency calls.
” Source location David John Briggs · 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 Deliver 5,000 additional staffed, permanent hospital beds and maintain this capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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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 Scale up national virtual ward capacity to more than 10,000 beds.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 action to improve ambulance response and patient handover times is assigned to South Yorkshire Integrated Care Board, as best placed to respond.
Verbatim wording from the response “Your report raised concerns about the capacity of Yorkshire Ambulance NHS Trust (YAS). You have appropriately shared your report and concerns with South Yorkshire Integrated Care Board, who are best placed to respond on the action being taken locally to improve ambulance response and patient handover times.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 2
Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays View source Excessive ambulance handover delays at hospitals 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. 4
Department of Health and Social Care
Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.
View source
Department of Health and Social Care
Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.
View source
Department of Health and Social Care
Scale up virtual ward capacity to more than 10,000 beds nationally.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective hospital discharge.
View source See 1 more action
×
AI-generated summary
KENNETH HEARD · 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 Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.
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 Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000.
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST . The winter months are likely to see an increase in demand for ambulance services and for hospital beds . December 2022 was the most demanding month of last year and featured the longest delays in response and handover . December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above.
” Source location KENNETH HEARD · 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 Excessive ambulance handover delays at hospitals
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital ,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital ,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST . The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000 .
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above.
” Source location KENNETH HEARD · Prevention of Future Deaths report
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 Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.
Verbatim wording from the response “Your report highlights that SWAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 to more than 10,000 beds nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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 SWAST and Royal Cornwall Hospital are best placed to respond on continuing local action to reduce handover delays and improve ambulance response times.
Verbatim wording from the response “Your report raised concerns about ambulance response times by South Western Ambulance Service NHS Foundation Trust (SWAST) and handover delays across the region. You have appropriately shared your report and concerns with SWAST and Royal Cornwall Hospital. SWAST and Royal Cornwall Hospital NHS Trust (RCHT), who are best placed to respond on the specific action they are continuing to take locally to reduce handover delays and improve ambulance response times.” Source location Response from Department of Health and Social Care
Open published response
15 Nov 2023 Lynda BLACKMORE · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital View source
Linked response
Aneurin Bevan University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Aneurin Bevan University LHB
Strengthen divisional structures by giving Urgent Care full responsibility for corporate site management and coordinated patient flow.
View source
Aneurin Bevan University LHB
Hold weekly Patient Safety Flow meetings with executive participation and action plans addressing patient flow and ambulance handover delays.
View source
Aneurin Bevan University LHB
Operate a Flow Centre that screens ambulance and general-practitioner admissions and streams patients to appropriate hospitals and departments.
View source
Aneurin Bevan University LHB
Redirect clinically appropriate patients with specified conditions to eLGH sites for more rapid assessment and treatment.
View source
Aneurin Bevan University LHB
Revise the escalation framework so ambulance handover delay escalation points are appropriate.
View source
Aneurin Bevan University LHB
Improve discharge-lounge use to create ward capacity and support ambulance handover times.
View source
Aneurin Bevan University LHB
Improve Same Day Emergency Care services at GUH and YYF Hospitals and increase patient selection to release emergency capacity.
View source
Aneurin Bevan University LHB
Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce patients awaiting discharge.
View source See 5 more actions
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AI-generated summary
Lynda BLACKMORE · 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
Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.
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 Handover delays impacting ambulance response times for patients requiring emergency treatment or conveyance to hospital
Wider context from the report “My concern here is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital . As Mr Garner stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016 .
Such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.
” Source location Lynda BLACKMORE · 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 Strengthen divisional structures by giving Urgent Care full responsibility for corporate site management and coordinated patient flow.
Verbatim wording from the response “Since this incident, a review of the Health Board’s Divisional structures have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays.” Source location Response from Aneurin Bevan University Health Board
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 weekly Patient Safety Flow meetings with executive participation and action plans addressing patient flow and ambulance handover delays.
Verbatim wording from the response “Other initiatives have seen the introduction of weekly Patient Safety Flow meetings during May 2023, chaired by the Deputy Director of Operations with input from the Executive team including the Chief Executive, Chief Operating Officer, Director of Nursing, Director of Therapies and Medical Director. These meetings focus on the delivery and performance of the Health Board’s ED and MIUs with very clear action plans to mitigate the risk and seek improvements in patient flow and ambulance handover delays. The focus has been on the following areas:” Source location Response from Aneurin Bevan University Health Board
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 Operate a Flow Centre that screens ambulance and general-practitioner admissions and streams patients to appropriate hospitals and departments.
Verbatim wording from the response “1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include:” Source location Response from Aneurin Bevan University Health Board
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 Redirect clinically appropriate patients with specified conditions to eLGH sites for more rapid assessment and treatment.
Verbatim wording from the response “1. Pre-Hospital / Flow Centre. Due to the unique nature of the Clinical Futures model that the Health Board manages, a Flow Centre is operated to ensure that all ambulance admissions (excepting life threatening emergencies) and admissions received from General Practitioners are screened to ensure that the patient is referred and streamed to the correct hospital and department. Further actions within this workstream include:” Source location Response from Aneurin Bevan University Health Board
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 Revise the escalation framework so ambulance handover delay escalation points are appropriate.
Verbatim wording from the response “2. Emergency Department/Assessment Area Focus” Source location Response from Aneurin Bevan University Health Board
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 Improve discharge-lounge use to create ward capacity and support ambulance handover times.
Verbatim wording from the response “3. Discharge Logistics” Source location Response from Aneurin Bevan University Health Board
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 Improve Same Day Emergency Care services at GUH and YYF Hospitals and increase patient selection to release emergency capacity.
Verbatim wording from the response “2. Workstream 2 Urgent & Emergency Care Redesign” Source location Response from Aneurin Bevan University Health Board
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 Introduce focused patient-safety events across Health Board sites to improve discharge processes and reduce patients awaiting discharge.
Verbatim wording from the response “3. Discharge Improvement to support more timely discharge and supporting people back to their own homes thereby reducing urgent and emergency care delays” Source location Response from Aneurin Bevan University Health Board
Open published response
Concerns raised 1
Delays in hospital handover reducing ambulance availability 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
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Speed up hospital discharges to support urgent and emergency care recovery.
View source
NHS England
Publish operational-resilience guidance focused on improving accident-and-emergency and ambulance handover times.
View source
Department of Health and Social Care
Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.
View source
Department of Health and Social Care
Scale up virtual ward capacity to more than 10,000 beds nationally.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective hospital discharge.
View source See 2 more actions
×
AI-generated summary
Lee Dryden · 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
Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.
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 hospital handover reducing ambulance availability
Wider context from the report “2. The Ambulance Service graded Lee's mother's call to them on the 15th December 2021 as a category 2 call which has two targets as described in evidence, the first being a response time of 20 minutes call time and that 9 out of 10 calls would be responded to within 40 minutes. Yorkshire Ambulance Service were unable to respond to Lee's call until 2 hours and 26 minutes had passed. Yorkshire Ambulance Service were on their highest level of escalation at that time with significant delays at hospital handover caused or contributed to the delay in an ambulance being available to Lee .
” Source location Lee Dryden · 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 Speed up hospital discharges to support urgent and emergency care recovery.
Verbatim wording from the response “NHS England recognises the significant pressure on ambulance services since the Covid-19 pandemic, which has seen longer response times across all categories than before the pandemic. That is why NHS England are focusing on improving ambulance performance for 2023/24, supported by the Delivery plan for recovering urgent and emergency care services, published in January 2023. The plan outlines the actions and steps that we are taking across England to recover and improve urgent and emergency care services, including improving ambulance response times for Category 2 incidents, increasing ambulance capacity through growing the workforce, speeding up discharges from hospitals, expanding new services in the community, and taking steps to tackle unwarranted variation in performance in the most challenged local systems.” Source location Response from NHS England
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 operational-resilience guidance focused on improving accident-and-emergency and ambulance handover times.
Verbatim wording from the response “In July 2023, we also published a letter to Integrated Care Boards, NHS Trusts and Primary Care Networks title Delivering operational resilience across the NHS this winter. This included focusing on improvements around Accident & Emergency handover and ambulance handover times.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from DHSC
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 to more than 10,000 beds nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from DHSC
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from DHSC
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.