Recurring concern

Delays in ambulance-to-hospital patient handover

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First reported 21 Jan 2014•Latest report 18 Jun 2026

Definition

What this concern includes

Includes delays, target failures, capacity pressures, admission barriers and ineffective improvement measures that directly concern the ambulance-to-hospital patient handover process.

Not included

  • Excludes delays in ambulance response that are not directly linked to hospital handover.
  • Excludes generic hospital staffing, social care, patient-flow or capacity deficiencies unless the report directly ties them to ambulance-to-hospital handover delays.
  • Excludes clinical handover failures between hospital wards or other services that do not concern ambulance-to-hospital patient transfer.
  • Excludes safety monitoring and clinical care while a patient waits where the assertion does not itself identify delayed handover.
Reports
77

Distinct published reports

Individual concerns
86

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
337

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care43
Welsh Ambulance Services NHS Trust20
NHS England18
Betsi Cadwaladr University LHB14
Welsh Government9
Aneurin Bevan University LHB4
Care Quality Commission4
Conwy County Borough Council4
Denbighshire County Council4
Flintshire County Council4
NHS West Yorkshire Integrated Care Board4
Wrexham County Borough Council4
East Midlands Ambulance Service NHS Trust3
Gwynedd Council3
Isle of Anglesey County Council3

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.

  1. Norfolk

    AI-generated summary

    Lyn Mary BRIND · Prevention of Future Deaths report

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

    Report summary

    Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain Emergency Department capacity for safe ambulance-to-hospital transfer

    Wider context from the report

    “6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. 7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. 8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. 7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community ”

    Source location

    Lyn Mary BRIND · Prevention of Future Deaths report
    Page 2 · concerns

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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 the plan’s measures to improve urgent-care waiting times and ambulance response times.

    Verbatim wording from the response

    “I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times, including to improve A&E wait times to 78% of patients being admitted, transferred, or discharged within four hours by March 2025. The plan also commits to reducing average Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 24 January 2023

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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 compared with 2022–23 plans.

    Verbatim wording from the response

    “and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 24 January 2023

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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

    Maintain the additional staffed hospital-bed capacity through 2024–25.

    Verbatim wording from the response

    “and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 24 January 2023

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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 hospital discharge.

    Verbatim wording from the response

    “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 24 January 2023

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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

    Ensure every acute hospital has access to a care transfer hub for complex discharges.

    Verbatim wording from the response

    “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 24 January 2023

    Open published response
  2. North West Wales

    AI-generated summary

    Glenys 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

    Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to implement an ambulance handover plan to reduce lost hours and improve ambulance availability

    Wider context from the report

    “3. Development of a pan Betsi Cadwaladr University Local Health Board ambulance handover plan to support reducing lost hours to improve performance and availability is still not in force and has been too slow ”

    Source location

    Glenys Roberts · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Share the local Ysbyty Gwynedd ambulance handover plan and related emergency department and hospital protocols across Health Board sites for local adoption.

    Verbatim wording from the response

    “The local Ysbyty Gwynedd handover plan has been shared across sites within the Health Board for local adoption, along with ED full protocols and hospital full protocols. These are aligned with the national Operational Pressures Escalation Levels (OPEL) with clear triggers to support de-escalation and reducing delays.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 25 October 2022

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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

    Maintain the Handover Improvement Plan with BCU Health Board and NCCU, using integrated commissioning action plans and fortnightly meetings to improve system flow and ambulance availability.

    Verbatim wording from the response

    “The Handover Improvement Plan has been put in place between the Trust, BCU Health Board and NCCU, along with fortnightly meetings chaired by NCCU. Going forward these meetings will be the host for integrated commissioning action plans, part of the refreshed Emergency Medical Services Commissioning Framework approved by Emergency Ambulance Services Committee.”

    Source location

    Response from Welsh Ambulance Services NHS Trust
    Page 2 · response
    Published 25 October 2022

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  3. Cheshire

    AI-generated summary

    Charles Stephen Rothwell · 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

    Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.

    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 handing over ambulance patients at A&E departments

    Wider context from the report

    “1) NWAS have developed a new triage system and have adopted NHS Pathways, which means that the initial call would now be triaged as Category 1 or 2. However, the problem of demand outstripping supply remains, such that if the same 999 call were made today the outcome would be the same. 2) NWAS continues to experience “exceptionally high demand” with the effect that “the demand completely outstrips the capability [they] have got.” 3) By way of example, I was told that yesterday afternoon Category 2 responses (which should attract attendance within 18 minutes) were sitting at an average of 75 minutes, Category 3 responses (which should attract attendance within 120 minutes) were sitting at an average of 10.5h and category 4 responses (which should prompt a further telephone assessment within 90 – 180 minutes) were sitting at an average of 11.5h. 4) With the approach of winter NWAS are also beginning to see an even greater increase in demand on top of the existing demand. 5) The problem is not due to a shortage of NWAS ambulances or staff but instead is the result of a wider issue linked to the lack of resources in primary, secondary and social care. This results in demand for ambulances outstripping supply and a backlog of ambulances waiting to handover patients at A&E departments because of a shortage of A&E beds, which in turn is because of shortages in social care. ”

    Source location

    Charles Stephen Rothwell · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue lobbying national bodies for changes to reduce hospital handover delays and improve ambulance capacity.

    Verbatim wording from the response

    “This is of course a system issue and AACE has constantly highlighted the impact of these delays on patients to both NHS England and DHSC. We will continue to do so and also support our members in engaging constructively with the wider health system to find solutions to the problem.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 10 October 2022

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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

    System-wide causes of ambulance delays must be addressed nationally by NHS England, the Department of Health and Social Care, and the wider health system.

    Verbatim wording from the response

    “As you have laid out in your fifth area above these are system issues and not merely ambulance issues and require a system led response to provide solutions. The following areas are contributing to ambulance response time delays nationally.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 2 · response
    Published 10 October 2022

    Open published response
  4. Birmingham and Solihull

    AI-generated summary

    Lee Anthony CARUANA · 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 Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.

    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 handing over ambulance patients at hospitals

    Wider context from the report

    “1. During the inquest, evidence was given on behalf of West Midlands Ambulance Service from Clinical Governance Lead ████████ and Trust Investigations Officer ████████ that at the time of Mr Caruana's death the Trust was experiencing unprecedented demand due to high call volume and delays in handing over patients to hospitals. At the time Mr Caruana was identified as needing an ambulance following a 999 call at 23:53 on the 6 October 2021, 71 of the Trusts 253 ambulance crews on duty were at hospital awaiting handover, the longest wait that day had been 7 hours and 45 minutes for a crew waiting at Birmingham Heartlands Hospital. 2. Since October 2021 the number of calls received has started to reduce to normal levels. However, the problem of paramedic crews being stuck at hospitals awaiting handover has increased. As an Investigations Officer ████████ said she is continuing to see incidents where ambulance attendance has been delayed because a crew was not available due to the number of crews waiting at hospital. Her evidence was that this is putting lives at risk. 3. ████████, Governance and Performance Manager at London Ambulance Service, gave evidence to the inquest as an independent expert. In the course of his evidence, he explained that the problem of ambulance crews being stuck awaiting handover is a national issue. Based on his anecdotal experience and observations the number of calls that a crew is able to attend to in a 12 hour shift has dropped by approximately 1/3 as a result of this issue. 4. The evidence from West Midlands Ambulance Service is that they have raised awareness of this issue locally, they have taken steps to free up ambulances (such as leaving multiple patients under the care of one paramedic crew at hospital to free up other crews to leave and diverting patients to other services where possible) and there is nothing further that they can do. 5. In the circumstances it is my conclusion that the availability of ambulance crews is being compromised by delays at hospitals resulting in delays in response times which creates a risk to life. ”

    Source location

    Lee Anthony CARUANA · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Issue a joint national letter requiring systems to address risks from prolonged ambulance handover delays.

    Verbatim wording from the response

    “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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 follow-up meetings with care systems and require them to set out plans for tackling handover delays and sharing system-level risks.

    Verbatim wording from the response

    “For NHS England (NHSE), resolving handover delays and the related impact on ambulance response is of the highest priority. A national letter (Appendix A) was issued jointly from NHSE and the Care Quality Commission in February 2022, setting out the need for integrated care systems to come together to address the risk of harm to patients in the community caused by long delays in handing over patients at Emergency Departments. This was followed up with meetings between systems and the NHSE Chief Operating Officer, where systems were asked to set out plans to tackle handover delays and share risks across health and care services at system level.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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 targeted and intensive support, including capital and revenue support where required, to trusts experiencing the greatest ambulance handover delays.

    Verbatim wording from the response

    “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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

    Develop a wider support programme for acute trusts to improve ambulance handover performance.

    Verbatim wording from the response

    “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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 across Integrated Care Boards to determine the capacity required to support performance and how it can be delivered.

    Verbatim wording from the response

    “NHSE continue to provide targeted support to some of the hospitals facing the greatest delays in the handover of patients, helping them to identify short- and longer-term interventions to improve delays and get ambulances swiftly back out on the road. The 10 trusts with the highest amount of hours lost to ambulance handover delays are receiving intensive support from NHSE (including capital and revenue as required). In addition, NHSE are developing a wider support programme for all acute trusts to deliver improvements in ambulance handover. Work is taking place across all Integrated Care Boards to determine the amount of capacity needed to support”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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

    Issue national guidance on increasing urgent and emergency care capacity and operational resilience, including action on Category 2 response times and ambulance handover delays.

    Verbatim wording from the response

    “In addition, NHSE set out the next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter, in a letter on 12 August 2022 (Appendix B). This again highlighted the need to target Category 2 response times and ambulance handover delays.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 20 September 2022

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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

    Continue exploring options to minimise hospital-discharge delays, including capacity for people needing ongoing non-acute care.

    Verbatim wording from the response

    “To drive further progress and support regional and local system arrangements, the Department has established a national discharge taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow. We will continue exploring options that minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of care.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 20 September 2022

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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

    Coordinate a system-wide programme with all partners to improve urgent and emergency care flow and reduce ambulance handover delays.

    Verbatim wording from the response

    “Birmingham and Solihull (BSOL) are very focused on the major risk posed by delay in ambulance handover to the care of others within the system. A major piece of work was instigated in late 2021, involving all partners, to ensure efficiency of flow within required pathways. This remains a major priority for the newly formed Integrated Care Board (ICB).”

    Source location

    Response from NHS Birmingham and Soilhull
    Page 1 · response
    Published 20 September 2022

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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

    Carry out a multi-stakeholder improvement event to achieve a further step change in urgent and emergency care delivery.

    Verbatim wording from the response

    “One of the major priorities of the newly formed ICB is an immediate commitment to production of a system wide Urgent and Emergency Care strategy involving all ICS stakeholders with a current two week multi-stakeholder improvement event to ensure a further step change in delivery. Governance arrangements have been further re-defined for strategic, tactical and operational interventions. This is in addition to an ongoing forensic focus, both within individual organisations and at system level, to ensure that flow through the relevant pathways with joined up, integrated working remains a high priority. This work is described in greater detail below.”

    Source location

    Response from NHS Birmingham and Soilhull
    Page 2 · response
    Published 20 September 2022

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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

    Increase use of Same Day Emergency Care and introduce surgical assessment virtual wards to support safe early discharge.

    Verbatim wording from the response

    “Same Day Emergency Care (SDEC)”

    Source location

    Response from NHS Birmingham and Soilhull
    Page 4 · response
    Published 20 September 2022

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission additional community beds and ambulance support for complex discharges to improve bed availability and discharge flow.

    Verbatim wording from the response

    “- Commissioned increase in community beds both within Birmingham Community Healthcare Trust and the independent sector to ensure bed availability is not a limiting factor to complex discharge from acute services. Close working with local authority colleagues with trusted assessor models has enabled efficiency in discharge both from acute sector beds and from community beds to final residential destination. This has also been aided by commissioning of additional ambulance support for complex discharge patients.”

    Source location

    Response from NHS Birmingham and Soilhull
    Page 6 · response
    Published 20 September 2022

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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

    Develop and fund the Birmingham and Solihull virtual-ward plan to support early discharge, admission avoidance and reduced ambulance turnaround times.

    Verbatim wording from the response

    “Virtual wards”

    Source location

    Response from NHS Birmingham and Soilhull
    Page 6 · response
    Published 20 September 2022

    Open published response
  5. North Wales (East and Central)

    AI-generated summary

    Raymond Gillespie · 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

    Raymond Gillespie, a care home resident with multiple comorbidities, suffered an unwitnessed fall on 8 October 2021 and waited almost 15 hours for a paramedic response after calls to the Welsh Ambulance Service Trust. The report identified delays caused by resource availability and ambulance handover delays, with a continuing risk of future deaths or harm while patients await transfer or community paramedic assistance.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Risk of deaths associated with delayed ambulance transfer or unavailability

    Wider context from the report

    “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call (2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021. (3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital. (4) The matters of concern herein are longstanding and despite proposed future action the concerns remain. ”

    Source location

    Raymond Gillespie · Prevention of Future Deaths report
    Page 2 · concerns

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in ambulance handovers across BCUHB sites

    Wider context from the report

    “(1) The first cause of the delay given was that all available resources were managing incidents of a higher acuity or same category but registered prior to this call (2) The second cause of the delay was a handover delay across all BCUHB sites. A total of 131.1 hours were lost in delay of handovers on 9 October 2021. (3) Whilst on the evidence it was not found that the delay contributed to Mr Gillespie’s death there remains a significant risk that deaths will continue to occur or that future deaths will occur either with patients waiting to be transferred into hospital from the ambulance or by ambulances not being available to those in the community requiring paramedic assistance and transfer to hospital. (4) The matters of concern herein are longstanding and despite proposed future action the concerns remain. ”

    Source location

    Raymond Gillespie · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Norfolk

    AI-generated summary

    Michael Nestor WYSOCKYJY · Prevention of Future Deaths report

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

    Report summary

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

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source location

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

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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

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

    Verbatim wording from the response

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

    Source location

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

    Open published response
  7. Manchester South

    AI-generated summary

    JOHN SCOTT MURPHY · Prevention of Future Deaths report

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

    Report summary

    John Scott Murphy, who had recently tested positive for Covid-19, deteriorated while alone at home and called the ambulance service at 03:20 on 11 July 2021. An ambulance arrived at 05:21, by which time he had died; the inquest concluded that the death was from natural causes, with Covid-19 pneumonitis and hypertensive heart disease recorded. The substantive concerns were delays in paramedics attending Category 2 calls due to staff and vehicle shortages, and ambulances being delayed at Accident and Emergency departments.

    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 ambulances clearing Accident and Emergency departments

    Wider context from the report

    “(2) The resources available in the North West Ambulance Service cannot be fully utilised because of the delays in ambulances clearing Accident and Emergency departments caused by the pressure on these departments across the NHS. ”

    Source location

    JOHN SCOTT MURPHY · 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

    Establish a national discharge taskforce comprising local government, NHS and national government representatives.

    Verbatim wording from the response

    “Finally, ambulance services across the country have been working closely with their local systems to reduce avoidable conveyance and support patients to get the care they need outside of hospital. Conveyance rates to Emergency Department are the lowest ever outside periods of national lockdown. To drive further progress and support regional and local system arrangements, we have established a national discharge taskforce with membership from local government, the NHS and national government. Local health and social care partners are already standing up the use of additional action to support discharge and improve patient flow.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 April 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue exploring options to minimise hospital-discharge delays, including capacity for people needing ongoing non-acute support.

    Verbatim wording from the response

    “We will continue exploring options that minimise delays to hospital discharge, including identifying capacity to accommodate people who no longer need acute hospital care while continuing to need other forms of support.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 April 2022

    Open published response
  8. Norfolk

    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. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Shaun Mansell · 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 Mansell, aged 50, was found deceased at home after an ambulance response to a 999 call was delayed by 8 hours and 15 minutes. The post-mortem cause of death was acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism, but the medical evidence could not determine whether the delay contributed to his death. The principal concerns were excessive ambulance handover delays at hospital and a welfare call during the delay that involved no direct contact with Shaun and was conducted by a paramedic without prior training for such calls.

    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

    Excessive delays in handing over patients at hospital

    Wider context from the report

    “(1) There were excessive delays in handing over patients at hospital. The West Midlands Ambulance Service issued a recent report found that there were excessive handover of patients at the Royal Stoke University Hospital, with some holding for over 4 hours. This impacted on the ability of the West Midlands Ambulance Service getting to patients. Oral evidence was given to the effect that this was a national issue, and not limited to the acute trusts within the West Midlands. ”

    Source location

    Shaun Mansell · 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

    Set a national policy requiring hospital handovers to take no more than 15 minutes.

    Verbatim wording from the response

    “I can confirm that national policy has set out that handovers should take no more than 15 minutes, ensuring patients receive necessary emergency care and allowing ambulances to get back on the road responding to patients in the community. We recognise however that hospital handover delays are a significant challenge for ambulance services and acute trusts both regionally and nationally and tackling this is a high priority for NHS England and NHS Improvement.”

    Source location

    2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 1 · response
    Published 18 November 2021

    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

    Work with ambulance services to eliminate hospital handover delays.

    Verbatim wording from the response

    “The NHS Long Term Plan made a commitment to work with ambulance services to eliminate hospital handover delays. Ambulance services continue to, where appropriate and safe to do so, use alternative approaches to taking patients to Emergency Departments (EDs) and therefore reduce front door congestion, including increasing use of ‘See and Treat’, and conveying patients to non-ED settings such as urgent treatment centres.”

    Source location

    2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 1 · response
    Published 18 November 2021

    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 systems to improve hospital flow by reducing length of stay and enabling timely discharge.

    Verbatim wording from the response

    “Handover delays can be linked to patient flow issues, and NHS England and NHS Improvement are also supporting systems to improve hospital flow through reducing length of stay and supporting timely discharge.”

    Source location

    2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 1 · response
    Published 18 November 2021

    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

    Reiterate communications to systems on eliminating ambulance handover delays and share measures addressing those delays.

    Verbatim wording from the response

    “On 13 December, as part of “Preparing the NHS for the potential impact of the Omicron variant and other winter pressures”, NHS England and NHS Improvement wrote to systems to reiterate earlier communication regarding the need to eliminate ambulance handover delays to ensure vehicles and paramedic crews are available to respond to urgent 999 calls. A range of measures, which have demonstrated benefits in addressing handover delays, were previously shared with all systems. I can also confirm that additional funding was made available for winter 2021/22 to support investment in Hospital Ambulance Liaison Officer staff to support handover of care.”

    Source location

    2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 18 November 2021

    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

    Make additional winter funding available to support investment in Hospital Ambulance Liaison Officer staff.

    Verbatim wording from the response

    “On 13 December, as part of “Preparing the NHS for the potential impact of the Omicron variant and other winter pressures”, NHS England and NHS Improvement wrote to systems to reiterate earlier communication regarding the need to eliminate ambulance handover delays to ensure vehicles and paramedic crews are available to respond to urgent 999 calls. A range of measures, which have demonstrated benefits in addressing handover delays, were previously shared with all systems. I can also confirm that additional funding was made available for winter 2021/22 to support investment in Hospital Ambulance Liaison Officer staff to support handover of care.”

    Source location

    2021-0383-Response-from-NHS-England-and-NHS-Improvement_Published
    Page 2 · response
    Published 18 November 2021

    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 length-of-stay reviews for long-stay patients to support discharge when clinically optimised.

    Verbatim wording from the response

    “5. UHNM undertakes ‘Length of Stay’ reviews for all long stay patients to ensure that they are discharged home as soon as optimized, whilst also recognising that this requires the support of our out of hospital providers of care as outlined above.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 2 · response
    Published 18 November 2021

    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

    Work with social care to increase domiciliary care access and placements for patients who do not need hospital admission.

    Verbatim wording from the response

    “8. We are working closely with social care to increase access to the domiciliary care market and placements for those patients that do not need to come into hospital. The NHS has also given Social Care over £4 million of funding to increase social care provision although we are yet to see the benefits of this.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 2 · response
    Published 18 November 2021

    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

    Work with NHS and social care colleagues to reduce hospital patients who no longer need inpatient beds and improve emergency department flow.

    Verbatim wording from the response

    “11. Over the last few months, we have seen a significant increase in the number of patients in our hospital beds that do not need to be there. We are therefore working hard with NHS and Social Care colleagues to reduce this number of patients which will in turn allow better flow of patients out of ED, reduce ED congestions and thus speed up the turnaround of ambulances.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 3 · response
    Published 18 November 2021

    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 and follow a standard operating procedure for safely managing ambulance arrivals when crews and patients must be held.

    Verbatim wording from the response

    “In addition to those points above and to ensure a safe and consistent approach in managing ambulance arrivals when there is a necessity to hold WMAS crew and patients on ambulances (due to capacity issues in the ED) a Standard Operating Procedure (SOP) was developed in February 2021; the staff in the ED follow this process on a daily basis.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 3 · response
    Published 18 November 2021

    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

    Ambulance delays are multifactorial and system-wide, so attributing the concern specifically to this Trust is not justified.

    Verbatim wording from the response

    “I understand that on the night in question, ambulances were delayed at UHNM as they were at most hospitals up and down the country, which is something that all of us in the wider economy work very hard to avoid. However, I cannot understand why UHNM would be singled out in this way, in relation to this incident, when the reason for ambulance delays at hospitals are multifactorial and rely on many system partners and organisations, including the ambulance service, to resolve. For example, delays can occur for the following reasons to name but a few:”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 1 · response
    Published 18 November 2021

    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

    Resolving ambulance delays requires action by ambulance, primary care, mental health, community and social care providers, not this Trust alone.

    Verbatim wording from the response

    “It is the responsibility of the Local Authority Social Care system and our system Community providers to deliver such ‘out of hospital’ services however, because of their own staffing and capacity constraints they are not able to take new patients. Therefore, both patients and the incumbent risks remain with the acute provider. The consequence of this lack of flow through the hospital generally which then impacts on Emergency Departments (ED) throughout the country; they become congested and ambulances have to wait to off load new patients.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 1 · response
    Published 18 November 2021

    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

    Without coordinated action by other health and care organisations, this Trust alone cannot reduce ambulance delays sufficiently.

    Verbatim wording from the response

    “As an organisation, we absolutely recognise the challenges that ‘ambulance holds’ have on both the ambulance service and our patients out in the community and we are committed to improving the current performance. However, we hope you can see from the above that an equal number of actions are required by other health and care organisations and without which, UHNM alone will not be able to make the difference required to reduce ambulance delays.”

    Source location

    2021-0383-Response-from-Royal-Stoke-University-Hospital_Published
    Page 3 · response
    Published 18 November 2021

    Open published response
  10. Gwent

    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
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Data last updated 7 September 2026