Recurring concern

Failure to provide timely medical review of emergency-department patients

First to latest report 11 Oct 2016 — 4 Feb 2025

Reports that mention this concern
8
Times this concern has been raised
9
Stated actions linked to this concern
7

What this concern includes

Includes failures in the emergency-department process to recognise, request, arrange or provide timely medical review for patients requiring it, including delays in doctor attendance, on-call response or escalation of high-priority patients; include associated medical-review failures where the patient is awaiting or receiving emergency-department care.

What is not included
  • Excludes delays in consultant review where consultant-level review is the specific concern and no broader emergency-department medical-review failure is identified.
  • Excludes ambulance response, hospital admission, diagnostic investigation or antibiotic-treatment delays when medical review is not the shared unsafe condition.
  • Excludes generic staffing, workload or communication deficiencies unless they directly result in delayed medical review of an emergency-department patient.
  • Excludes failures occurring after timely medical review has been provided, including subsequent treatment or discharge decisions.

Reports and published responses 8 reports

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

  1. North East Kent

    AI-generated summary

    Dorothy Lilian REID · 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

    Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.

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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 emergency department patients being seen by a doctor

    Wider context from the report

    “(1) During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death. ”

    Source location

    Dorothy Lilian REID · 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

    Publish the NHS mandate and planning guidance prioritising and detailing improvements to A&E and ambulance waiting times.

    Verbatim wording from the response

    “On 30 January 2025, the Government published ‘Road to recovery: the government’s 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 7 February 2025

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Increase same-day emergency care so more patients are seen, treated and discharged within one day.

    Verbatim wording from the response

    “The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:”

    Source location

    Response from DHSC
    Page 2 · response
    Published 7 February 2025

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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

    Undertake regional Emergency Department quality and safety visits to identify challenges and support safe care and performance improvement.

    Verbatim wording from the response

    “NHS England’s South East region has undertaken Quality & Safety visits to EDs across the region to understand the challenges faced in delivering safe and effective care. This has identified next steps, to include sharing learning and best practice, and ensuring a quality and safety focus on performance recovery and improvement.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 7 February 2025

    Open published response

  2. North West Wales

    AI-generated summary

    JAMES JONES · 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

    James Jones was taken to hospital with abdominal and chest pain, vomiting, reduced bowel movements and reduced urine output, and was later assessed as having a small bowel obstruction. He experienced delays in medical review, scanning and preparation for exploratory surgery, waiting 17.5 hours before being taken to the anaesthetic room, where he suffered a cardiac arrest. The concerns identified were pressures and insufficient staffing in the Accident and Emergency department, potentially leading to delayed reviews and missed opportunities that may prove fatal in similar cases.

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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 review triage category 2 patients within the intended timeframe

    Wider context from the report

    “(1) Continued pressures within the Accident and Emergency department at Ysbyty Gwynedd will result in: (a) Doctors not having the capacity to review patients in line with the “aim” e.g within 10 minutes for triage category 2 patients. (b) Missed opportunities that may prove fatal (2) Current staffing levels being insufficient to meet demand and safely care for patients Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur. ”

    Source location

    JAMES JONES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Celia Sanderson · 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

    Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

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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 Emergency Department senior clinician review due to insufficient senior medical staffing

    Wider context from the report

    “2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors. Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced. Historically that had been a quieter period however demands on ED meant that was no longer the case. As a consequence senior reviews of patients were further delayed. An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate; ”

    Source location

    Celia Sanderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in Emergency Department clinician review due to patient volume and insufficient staff availability

    Wider context from the report

    “1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time. The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them; ”

    Source location

    Celia Sanderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.

    Verbatim wording from the response

    “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 24 February 2023

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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

    Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.

    Verbatim wording from the response

    “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 24 February 2023

    Open published response

  4. Blackpool and the Fylde

    AI-generated summary

    Douglas OWENS · 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

    Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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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 provide on-call specialist review in the Emergency Department when needed

    Wider context from the report

    “(2) That the Deceased was not seen by a speciality doctor in the Emergency Department notwithstanding the need for him to be seen. Unless action is taken there may be a continuing risk that patients in the Emergency Department will not be seen by on call doctors in speciality disciplines, in particular, ophthalmology, even when the need arises in that Department. ”

    Source location

    Douglas OWENS · 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

    Develop and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.

    Verbatim wording from the response

    “The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

    Source location

    2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
    Page 1 · response
    Published 3 December 2020

    Open published response

  5. Bedfordshire and Luton

    AI-generated summary

    Sarah YOUNG · 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

    Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

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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 provide timely Medical Team review and diagnostic support after referral

    Wider context from the report

    “(1) Although Sarah was referred to the Medical Team at 20:00 on 9 April 2019 whilst she still in the Emergency Department awaiting the CT venogram, she was never seen by them. The evidence to the Inquest from the Medical Registrar on call that evening was that “if a decision to admit to ITU is made, an immediate or urgent medical review is not required, as the patient is under the direct care of the ITU team” yet the evidence from one of the ITU Consultants in charge of her care was that the ITU Team do rely on the Medical Team to assist in progressing a diagnosis( including involving a Neurologist where required) and that it was a matter of regret for him that there had not been more Medical advice in this case; ”

    Source location

    Sarah YOUNG · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Northamptonshire

    AI-generated summary

    Susan Sterland · 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

    Susan Sterland was brought to Kettering General Hospital on 29 December 2018 with an intestinal obstruction that was not diagnosed, and was admitted after being diagnosed with constipation. Her condition deteriorated, care was not escalated, and she collapsed and died early on 31 December 2018. The principal concern was that she was not seen by a senior doctor despite deterioration and remaining in hospital for about 40 hours; the report states that earlier senior review might have led to investigation and earlier diagnosis.

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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 provide senior doctor review for deteriorating patients

    Wider context from the report

    “This was obviously a very busy time at the hospital. However, Ms Sterland was in the hospital for some 40 hours, she was not getting better, there were signs that she was deteriorating during the late morning and afternoon of 30 December, there was a plan to admit her to a ward but there were no beds available. My concern is that in this situation she was not seen by a senior doctor. If Ms Sterland had been seen by a senior doctor the evidence was that she would have had further investigation which would have led to earlier diagnosis of the obstruction and may have altered the outcome. The evidence at the inquest suggested that there are some categories of patients in the emergency department for whom a senior review is mandatory. It may be that the Trust would wish to consider whether the circumstances of this case suggest that there are other situations in which a senior review should be required. ”

    Source location

    Susan Sterland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ratify and implement an updated ED standard operating policy defining responsibility for each patient and escalation arrangements.

    Verbatim wording from the response

    “1. A revision to the Standard Operating Practice to set out who is responsible for reviewing patients:”

    Source location

    2020-0062-Response-from-Kettering-General-Hospital_Redacted
    Page 2 · response
    Published 20 March 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Increase daily senior decision-making capacity by adding middle-grade shifts and a second consultant shift in the Emergency Department.

    Verbatim wording from the response

    “The Department medical rota has been changed to increase the number of senior decision makers present within the department on each day. As a result the number of middle-grade shifts has been increased from 9 to 11 shifts, daily. In addition, the number of consultants in the department has been increased by adding a second consultant shift from 15:00 to 22.00 and we are aiming to have 2 consultants in ED from 08:00 to 22.00. This will allow a timely senior review of patients and will provide consultant ward rounds for EDU.”

    Source location

    2020-0062-Response-from-Kettering-General-Hospital_Redacted
    Page 2 · response
    Published 20 March 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create a new EDU operating policy specifying consultant ward-round responsibility, patient ownership and risks identified in the report before recommissioning.

    Verbatim wording from the response

    “The EDU was decommissioned in March 2020 in response to Covid 19. The area where EDU was located is currently being used as ED Major cubicles which are part of the ED footprint.”

    Source location

    2020-0062-Response-from-Kettering-General-Hospital_Redacted
    Page 2 · response
    Published 20 March 2020

    Open published response

  7. Manchester South

    AI-generated summary

    Novia Emilia Delima · 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

    Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.

    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

    Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care

    Wider context from the report

    “2. The inquest heard that very young babies present significant challenges in diagnosis and early clinical input by a clinician experienced in dealing with young children was important. The trust had brought in significant changes to how it dealt with paediatric cases in ED since the death of Novia. This includes early clinical involvement of a paediatric clinician for babies between 0- 6 months due to their recognition of challenges of diagnosis in very young children. The inquest heard that not all trusts, nationally, have systems that ensure very young children are seen by a paediatrician at an early stage particularly in an OOH situation. ”

    Source location

    Novia Emilia Delima · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Blackpool and the Fylde

    AI-generated summary

    Barry THOMPSON · Prevention of Future Deaths report

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

    Report summary

    Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

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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 timely medical review and antibiotic treatment for high-priority patients

    Wider context from the report

    “(1) Non-compliance with National and Local protocols: Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately. ”

    Source location

    Barry THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026