Concerns raised 1
Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
KENNETH HEARD · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Seasonal increases in ambulance and hospital demand creating risk of life-threatening delays
Wider context from the report “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro.
(8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows:
5,107 hours lost at Derriford Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36
2,449 hours lost at Treliske Hospital,
Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13
(9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below.
Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes
Time Lost in June 2023
Time Lost in July 2023
Time Lost in August 2023
Derriford Hospital 4714:17 3436:41 5107:36
Treliske Hospital 2833:15 2386:23 2449:47
(10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000.
(11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST . The winter months are likely to see an increase in demand for ambulance services and for hospital beds . December 2022 was the most demanding month of last year and featured the longest delays in response and handover . December 2023 is likely to be the most demanding month of this year.
(12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above.
” Source location KENNETH HEARD · Prevention of Future Deaths report
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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 Expand ambulance capacity through additional funding and maintain the additional capacity in 2024/25.
Verbatim wording from the response “Your report highlights that SWAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.” Source location Response from Department of Health and Social Care
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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 Deliver 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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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 Scale up virtual ward capacity to more than 10,000 beds nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
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28 Jun 2023 Hilary THOMAS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Insufficient hospital resources to manage patient volume View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Department of Health and Social Care
Deliver and maintain an uplift of 5,000 staffed, permanent hospital beds to increase capacity and improve patient flow.
View source
Department of Health and Social Care
Scale virtual ward capacity to more than 10,000 beds nationally to support hospital capacity and patient flow.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective discharge from hospital.
View source
University Hospitals Birmingham NHS Foundation Trust
Provide two dedicated consultants for emergency surgical patients across the Birmingham Heartlands and Queen Elizabeth sites.
View source
University Hospitals Birmingham NHS Foundation Trust
Appoint specialised Emergency General and Trauma Surgeons at the Queen Elizabeth site.
View source
University Hospitals Birmingham NHS Foundation Trust
Operate a virtual ward managed by specialist nurses for ambulatory emergency patients.
View source
University Hospitals Birmingham NHS Foundation Trust
Expand the virtual ward to the Trust’s other acute sites by 31 October 2023.
View source
University Hospitals Birmingham NHS Foundation Trust
Expand the Emergency General Surgery service by two consultants by the end of 2023.
View source
University Hospitals Birmingham NHS Foundation Trust
Initiate hot clinics to expedite ambulatory patient review and reduce pressure on the Surgical Admissions Unit and Emergency Department.
View source See 6 more actions
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AI-generated summary
Hilary THOMAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient hospital resources to manage patient volume
Wider context from the report “1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume . This had a direct impact on Mrs Thomas's death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the department.
” Source location Hilary THOMAS · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and maintain an uplift of 5,000 staffed, permanent hospital beds to increase capacity and improve patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scale virtual ward capacity to more than 10,000 beds nationally to support hospital capacity and patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective discharge from hospital.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide two dedicated consultants for emergency surgical patients across the Birmingham Heartlands and Queen Elizabeth sites.
Verbatim wording from the response “These responses include:” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Appoint specialised Emergency General and Trauma Surgeons at the Queen Elizabeth site.
Verbatim wording from the response “These responses include:” Source location Response University Hospitals Birmingham NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a virtual ward managed by specialist nurses for ambulatory emergency patients.
Verbatim wording from the response “• The creation of a virtual ward, managed by new specialist nurses, so that emergency patients can be managed on an ambulatory basis. This has saved over 1000 bed days this year and reduced the workload for the junior doctors on the QE site. This will be expanded to the Trust’s other acute sites by 31 October 2023.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Expand the virtual ward to the Trust’s other acute sites by 31 October 2023.
Verbatim wording from the response “• The creation of a virtual ward, managed by new specialist nurses, so that emergency patients can be managed on an ambulatory basis. This has saved over 1000 bed days this year and reduced the workload for the junior doctors on the QE site. This will be expanded to the Trust’s other acute sites by 31 October 2023.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Expand the Emergency General Surgery service by two consultants by the end of 2023.
Verbatim wording from the response “• Expansion of the EGS service by another two consultants by the end of 2023. This expansion will support the initiation of so called ‘Hot clinics’ for the expedited review of ambulatory patients. This will allow patients to bypass the Surgical Admissions Unit (SAU) and thereby reducing the load on junior doctors working in that area and the Emergency Department. It will lead to improved patient experience and reduce the number of patients in ED and SAU, allowing those units to focus on caring for the more unwell patients.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 Initiate hot clinics to expedite ambulatory patient review and reduce pressure on the Surgical Admissions Unit and Emergency Department.
Verbatim wording from the response “• Expansion of the EGS service by another two consultants by the end of 2023. This expansion will support the initiation of so called ‘Hot clinics’ for the expedited review of ambulatory patients. This will allow patients to bypass the Surgical Admissions Unit (SAU) and thereby reducing the load on junior doctors working in that area and the Emergency Department. It will lead to improved patient experience and reduce the number of patients in ED and SAU, allowing those units to focus on caring for the more unwell patients.” Source location Response University Hospitals Birmingham NHS Foundation Trust
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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 The Trust is responsible for locally increasing hospital capacity and resources to manage increased patient attendances.
Verbatim wording from the response “Your report raised concerns about the capacity of Birmingham Heartlands Hospital to deal with the volume of patient attendances. I note that the University Hospitals Birmingham NHS Foundation Trust has written to you separately. The trust’s response acknowledges the emergency general surgery service has become increasingly busy following the pandemic. The trust has set out the specific actions they are taking locally to increase capacity and resources to manage the increased volume of patient attendances. This includes the provision of additional consultant resource.” Source location Response from Department of Health and Social Care
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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 Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.
Verbatim wording from the response “This area of concern is for the Department of Health and Social Care however we acknowledge that there has been a significant increase in demand for assessment by the Emergency General Surgery (EGS) Service at UHB. This was the service to which Mrs Thomas was appropriately referred by the Emergency Department. In this case failure of assessment and escalation occurred after this referral. She was seen by the EGS service at 11:30am by an experienced Specialist Registrar (SpR) who was in the 7th Year of specialist training (ST7). When that SpR returned at 20:00 Mrs Thomas, after waiting for so long, had taken her own discharge. We acknowledge that Mrs Thomas had to wait far too long and that this was a failure of the EGS service.” Source location Response University Hospitals Birmingham NHS Foundation Trust
Open published response
15 Oct 2019 Mr Derek Weaver · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 1
Lack of capacity for regional referrals during surges View source
Linked responses
Department of Health and Social Care Guy'S and St Thomas' NHS Foundation Trust NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
NHS England
Keep thoracic surgery pathway performance and access under review.
View source
Guy'S and St Thomas' NHS Foundation Trust
Introduce a consultant-of-the-week system to triage and manage all thoracic surgery referrals.
View source
Guy'S and St Thomas' NHS Foundation Trust
Audit the consultant-of-the-week system to assess whether it improves transfer management.
View source
Guy'S and St Thomas' NHS Foundation Trust
Transfer bed allocation and urgent thoracic surgery transfers to the Site Management Team using a three-level urgency and transfer process.
View source
Guy'S and St Thomas' NHS Foundation Trust
Increase Guy’s Hospital thoracic surgery bed capacity by switching wards and completing necessary estate works.
View source See 2 more actions
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AI-generated summary
Mr Derek Weaver · 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
Mr Derek Weaver was admitted to hospital with community-acquired pneumonia and an empyema, which required surgery. He died on 31 May 2018 after becoming septic and developing a systemic inflammatory response following delayed transfer for surgery. The principal concern was that the 14-day transfer delay, related to exceptional pressure on bed capacity, contributed to his death and that similar risks could recur during referral surges without additional capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of capacity for regional referrals during surges
Wider context from the report “A consultant thoracic surgeon who was involved in his care after transfer said that had a higher chance of death because surgery was at a time of SIRS. If he had been transferred earlier he would have had surgery when he was not septic. It would have been two stages, the first being key hole surgery, with mortality of only 1 in 100. That may have obviated the necessity of second stage decortication surgery, with mortality of 5%, but it was probably needed anyway. The delay in transfer related to a surge in referrals, limiting capacity. Most regional referrals of this sort needed to be treated at weekends to maintain treatment of cancer cases in the week. There had been pressure to secure greater resources. The risk of potentially preventable deaths will recur whenever there is such a surge in referrals and be mitigated by provision of more beds.
” Source location Mr Derek Weaver · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Keep thoracic surgery pathway performance and access under review.
Verbatim wording from the response “Within London we do have other thoracic providers (eg. University College Hospitals and Imperial Hospitals amongst others) so there is the possibility to change the thoracic surgery pathway for both lung cancer patients and patients with conditions such as empyema that require urgent surgery too, if we felt insufficient progress was being made on meeting the nationally set response standards. We can confirm we will keep this under review as we recognise the importance of making sure that all patients needing thoracic surgery can get quick access to high quality services.” Source location 2019-0345-Response-from-NHS-England-Redacted-1
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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 Introduce a consultant-of-the-week system to triage and manage all thoracic surgery referrals.
Verbatim wording from the response “In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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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 Audit the consultant-of-the-week system to assess whether it improves transfer management.
Verbatim wording from the response “In April 2019, to improve the Thoracic Surgery Service, the referrals system was changed to a “consultant of the week” system. A single consultant and their team take responsibility for the triage and management of all referrals for the week, with the aim of improving the prioritisation of patients for transfer in to the Thoracic Surgery Service. The “consultant of the week” system will be audited to ascertain whether it has improved the management of transfers in.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transfer bed allocation and urgent thoracic surgery transfers to the Site Management Team using a three-level urgency and transfer process.
Verbatim wording from the response “In October 2019, to mitigate the risk of capacity issues impacting on transfers, the Directorate Management Team transferred the management of the Thoracic Surgery Service’s beds and urgent transfer process to the Site Management Team. This change aligned the Thoracic Surgery Service with other services across the Trust. The process, set out in the UTCI Flow Chart (appendix 1), enables the Thoracic Surgery Service to triage its patients into three categories (1) Admission not urgent, (2) Urgent – Needs admission within 48 hours and (3) Urgent – Needs admission immediately and for the appropriate transfer to be arranged.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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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 Guy’s Hospital thoracic surgery bed capacity by switching wards and completing necessary estate works.
Verbatim wording from the response “The Trust is looking towards an electronic referral system that allows local specialist services to manage their own tertiary referrals and gives the Site Management Team an overview of the current waiting list. In addition, the Trust Operational Board is currently looking to increase the number of beds on the Guy’s Hospital site for Thoracic Surgery patients. This will be achieved through switching the wards on which services are provided and undertaking the necessary estate works. It is expected that the increased capacity will be available during the first quarter of 2020.” Source location 2019-0345-Response-by-Guys-and-St-Thomas-NHS-Trust
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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 Peer review and surveillance identified no serious quality or safety concerns in London thoracic services.
Verbatim wording from the response “I am advised that NHS England’s national Specialised Commissioning Quality Team has undertaken peer review and surveillance activities of thoracic services in London, including at the Guy’s and St Thomas’ NHS Foundation Trust where no serious quality or safety concerns were identified. I am further advised that NHSEI will maintain oversight to ensure patients requiring thoracic surgery can access the service in a timely way, according to their clinical condition. This will include reviews of bed capacity in response to the ambition set out in the NHS Long Term Plan, for earlier and faster diagnosis of cancer¹ and the impact this might have on related services such as critical care beds.” Source location 2019-0345-Response-from-the-Department-of-Health
Open published response
2 Jun 2014 Jennifer Morrison · Prevention of Future Deaths report Wirral
View report summary
Concerns raised 1
Insufficient staffing and bed capacity to maintain timely patient care during demand spikes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Wirral University Teaching Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Wirral University Teaching Hospital NHS Foundation Trust
Review and revise the Escalation Policy for demand, bed-capacity and clinical-risk management.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Develop the 2014/15 Winter Operational Plan using lessons from previous experience.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Review the organisation’s funded nursing establishment to identify staffing requirements.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Invest in areas, including the Surgical Assessment Unit, that do not meet required nurse-to-patient ratios.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Produce monthly reports for the Director of Nursing on ward staffing levels.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Actively manage sickness absence under the Attendance Capability Policy.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Hold daily Surgical Division management meetings to review staffing levels on each ward.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Increase junior doctor presence in the Emergency Surgical Assessment Unit.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Introduce twice-daily on-call consultant rounds in the Emergency Surgical Assessment Unit.
View source
Wirral University Teaching Hospital NHS Foundation Trust
Conduct regular staffing reviews in the Emergency Surgical Assessment Unit.
View source See 7 more actions
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AI-generated summary
Jennifer Morrison · 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
Jennifer Morrison had significant breathing difficulties, fell at home on 30 December 2012, was admitted to hospital, deteriorated despite treatment, and died following a cardiac arrest on 9 January 2013. Concerns included missing hospital observation records and whether staffing pressures and delays in early January affected the care provided, including delays in transfer to a High Dependency Unit and in restarting fluids.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staffing and bed capacity to maintain timely patient care during demand spikes
Wider context from the report “2. Evidence was given by a Consultant Surgeon which raises concern as regards the level of care afforded to patients during the first week to ten days of January. The amount of time the Deceased spent on an assessment unit was longer than indicated by Trust guidance, which was attributed to a shortage of beds , and the higher number of patients attending the hospital after the Christmas / New Year holiday season than may be expected at other times during the year which contributed to a delay in the Deceased being treated on a High Dependency Unit . Similarly, a decision having been appropriately made that she undergo an endoscopy procedure for which she would need to remain “nil by mouth”, the Consultant acknowledged that the period of time she remained nil by mouth was “contributed to by the delay over Christmas” and that “she could have moved on to fluids sooner”, the implication again being that the number of patients waiting until after the holiday season before attending the hospital was having an impact on the staffing levels during early January and therefore on the standard of care afforded to the patients. I was concerned that the Trust could do more to ensure that the care afforded to patients was not jeopardised due to staffing levels being unable to cope with a spike in the numbers of patients waiting until after the New Year to visit hospital .
” Source location Jennifer Morrison · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and revise the Escalation Policy for demand, bed-capacity and clinical-risk management.
Verbatim wording from the response “within acceptable limits. The policy defines thirteen ‘trigger points’ in terms of emergency department activity levels and bed capacity, and includes clear criteria for prioritising patients for allocation to beds. There are four states of alert: red, amber, yellow and green; and when a trigger point is breached, the hospital moves to a higher state of alert. At higher states of alert, the frequency of bed management meetings increases and they are attended by more senior personnel, along with colleagues from other organisations in the local health economy. Escalation areas are put into use if needed, and patients are identified who may be suitable for early discharge. This policy was recently reviewed in the light of experience and a new version came into force in June 2014.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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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 Develop the 2014/15 Winter Operational Plan using lessons from previous experience.
Verbatim wording from the response “Although levels of activity in the hospital can vary unexpectedly from day to day and week to week, there are generally seasonal patterns of demand for services, with demand peaking in winter. Every year, the Trust produces a Winter Operational Plan to manage these demand pressures. This is developed well in advance, and the 2014/15 plan is being drafted at the time of writing. Each year’s plans take into account lessons learned from previous years’ experience. An outline of this particular case has been shared with those involved in producing the plan.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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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 Review the organisation’s funded nursing establishment to identify staffing requirements.
Verbatim wording from the response “The Trust is taking action to ensure safe staffing levels throughout the year, not just in winter. The nursing establishment (the number of funded nursing posts in the organisation) has been reviewed, and investment made in areas – including the Surgical Assessment Unit – which did not meet the required nurse: patient ratio. Monthly reports are produced for the Director of Nursing which show the nurse staffing levels on each ward. This reflects the emphasis which was placed on staffing levels by the Francis Inquiry, the Keogh reviews of hospitals with high mortality rates, and Professor Don Berwick’s report on the state of the NHS. We are actively managing sickness absence through our Attendance Capability Policy. There has been a steady decrease and at the end of the 2013/14 financial year the level of sickness absence was 4.68%. Our target is to reduce this to 4.00%.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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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 in areas, including the Surgical Assessment Unit, that do not meet required nurse-to-patient ratios.
Verbatim wording from the response “The Trust is taking action to ensure safe staffing levels throughout the year, not just in winter. The nursing establishment (the number of funded nursing posts in the organisation) has been reviewed, and investment made in areas – including the Surgical Assessment Unit – which did not meet the required nurse: patient ratio. Monthly reports are produced for the Director of Nursing which show the nurse staffing levels on each ward. This reflects the emphasis which was placed on staffing levels by the Francis Inquiry, the Keogh reviews of hospitals with high mortality rates, and Professor Don Berwick’s report on the state of the NHS. We are actively managing sickness absence through our Attendance Capability Policy. There has been a steady decrease and at the end of the 2013/14 financial year the level of sickness absence was 4.68%. Our target is to reduce this to 4.00%.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce monthly reports for the Director of Nursing on ward staffing levels.
Verbatim wording from the response “The Trust is taking action to ensure safe staffing levels throughout the year, not just in winter. The nursing establishment (the number of funded nursing posts in the organisation) has been reviewed, and investment made in areas – including the Surgical Assessment Unit – which did not meet the required nurse: patient ratio. Monthly reports are produced for the Director of Nursing which show the nurse staffing levels on each ward. This reflects the emphasis which was placed on staffing levels by the Francis Inquiry, the Keogh reviews of hospitals with high mortality rates, and Professor Don Berwick’s report on the state of the NHS. We are actively managing sickness absence through our Attendance Capability Policy. There has been a steady decrease and at the end of the 2013/14 financial year the level of sickness absence was 4.68%. Our target is to reduce this to 4.00%.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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 Actively manage sickness absence under the Attendance Capability Policy.
Verbatim wording from the response “The Trust is taking action to ensure safe staffing levels throughout the year, not just in winter. The nursing establishment (the number of funded nursing posts in the organisation) has been reviewed, and investment made in areas – including the Surgical Assessment Unit – which did not meet the required nurse: patient ratio. Monthly reports are produced for the Director of Nursing which show the nurse staffing levels on each ward. This reflects the emphasis which was placed on staffing levels by the Francis Inquiry, the Keogh reviews of hospitals with high mortality rates, and Professor Don Berwick’s report on the state of the NHS. We are actively managing sickness absence through our Attendance Capability Policy. There has been a steady decrease and at the end of the 2013/14 financial year the level of sickness absence was 4.68%. Our target is to reduce this to 4.00%.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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 Hold daily Surgical Division management meetings to review staffing levels on each ward.
Verbatim wording from the response “Within the Surgical Division, there is now a daily management meeting to review staff levels on each of the wards. This was introduced approximately six months ago.” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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 junior doctor presence in the Emergency Surgical Assessment Unit.
Verbatim wording from the response “Surgical Assessment Unit
Mrs Morrison was a patient on the Surgical Assessment Unit (SAU). Earlier this year the SAU was the subject of a ‘Listening into Action’ project. Listening into Action is an initiative which brings together multi-disciplinary groups of staff at all levels to identify what a good service looks like, what they hope to achieve within six months, and a list of high-impact short-term actions which will help the service to get there. The actions arising from the project included increasing the junior doctor presence, introducing twice daily on-call consultant rounds and regular staffing reviews to ensure sufficient staffing levels. The unit has been re-named the” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce twice-daily on-call consultant rounds in the Emergency Surgical Assessment Unit.
Verbatim wording from the response “Surgical Assessment Unit
Mrs Morrison was a patient on the Surgical Assessment Unit (SAU). Earlier this year the SAU was the subject of a ‘Listening into Action’ project. Listening into Action is an initiative which brings together multi-disciplinary groups of staff at all levels to identify what a good service looks like, what they hope to achieve within six months, and a list of high-impact short-term actions which will help the service to get there. The actions arising from the project included increasing the junior doctor presence, introducing twice daily on-call consultant rounds and regular staffing reviews to ensure sufficient staffing levels. The unit has been re-named the” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
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 regular staffing reviews in the Emergency Surgical Assessment Unit.
Verbatim wording from the response “Surgical Assessment Unit
Mrs Morrison was a patient on the Surgical Assessment Unit (SAU). Earlier this year the SAU was the subject of a ‘Listening into Action’ project. Listening into Action is an initiative which brings together multi-disciplinary groups of staff at all levels to identify what a good service looks like, what they hope to achieve within six months, and a list of high-impact short-term actions which will help the service to get there. The actions arising from the project included increasing the junior doctor presence, introducing twice daily on-call consultant rounds and regular staffing reviews to ensure sufficient staffing levels. The unit has been re-named the” Source location 2014-0265-Response-by-Wirral-University-Teaching-Hospital
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.