Recurring concern

Unsafe emergency-department crowding leaving patients without appropriate clinical space

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First reported 24 Dec 2015•Latest report 18 Jun 2026

Definition

What this concern includes

Includes crowding or capacity failures that leave emergency-department patients without an appropriate clinical space.

Not included

Excludes generic emergency department crowding, staffing pressure or delayed patient flow unless the report directly identifies the resulting lack of designated clinical space or non-clinical-space care.
Excludes failures concerning psychiatric, inpatient or other specialist bed capacity unless they specifically concern designated clinical space for emergency department patients.
Excludes isolated clinical-care, monitoring, privacy, documentation or treatment failures that do not identify inadequate designated emergency department care space as the shared unsafe condition.

Reports: 17
Individual concerns: 19
Date range: 2015–2026
Stated actions: 117

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care11

NHS England4

University Hospitals Sussex NHS Foundation Trust3

Care Quality Commission2

Greater Manchester Health and Social Care Partnership2

Barts Health NHS Trust1

Betsi Cadwaladr University LHB1

Cwm Taf Morgannwg University Local Health Board1

James Paget University Hospital1

NHS Norfolk and Suffolk Integrated Care Board1

Norfolk and Norwich University Hospital1

Norfolk and Suffolk NHS Foundation Trust1

Royal Cornwall Hospitals NHS Trust1

Royal United Hospital1

South West Ambulance Service Trust (SWAST)1

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.

18 Jul2023
North Wales (East and Central)
Concerns raised1
1. Insufficient space for nursing care and pressure-area assessment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Philip Hawkins · 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

Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient space for nursing care and pressure-area assessment
Wider context from the report
“Care Concerns in the ED 4. On 18.03.22 at 02:49 there was no space for a nurse to attend to Mr Hawkins’ personal care needs or assess his pressure areas. 5. On 19.03.23 at 12:18, Mr Hawkins needed ‘repeat bloods’ but this was never done nor highlighted to clinicians. 6. On 19.03.23 at 00:31 Mr Hawkins was given oxygen but there are no nursing notes to indicate why or whether this was discussed with a clinician. 7. There is no written nursing documentation in relation to Mr Hawkins’ care from 21:52 on 19.03.23. 8. Mr Hawkins was nil by mouth but this was not made known to visitors who fed him. ”
Source location
Philip Hawkins · Prevention of Future Deaths report
Page 1 · concerns
Open source report
6 Jan2022
Norfolk
Concerns raised1
1. Reliance on safety checks for patients left in ambulances because of emergency department space delays
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
2. Action
  Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
3. Action
  Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
1. Action
  Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.
  Stated by NHS Norfolk and Suffolk Integrated Care BoardStated completed
2. Action
  Deliver six new ambulance hubs to reduce handover delays.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.
  Stated by Department of Health and Social CareStated in progress
4. Action
  Provide 5,000 additional staffed permanent hospital beds.
  Stated by Department of Health and Social CareStated planned
5. Action
  Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.
  Stated by Department of Health and Social CareStated in progress
6. Action
  Establish Same Day Emergency Care services across every hospital with a major emergency department.
  Stated by Department of Health and Social CareStated planned
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
Reliance on safety checks for patients left in ambulances because of emergency department space delays
Wider context from the report
“(2) As there had been known delays in obtaining space in the emergency department at the Trust senior clinicians undertook a safety check of those patients left in ambulances to assess the urgency and need for a trolley or bed. ”
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
Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.

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
Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.

Verbatim wording from the response
“The ICB coordinated systemwide adoption in October 2022 of the Professional Standards of Care for Patients Waiting in Ambulances to ensure patients awaiting handover to ED receive consistent, timely and clinically appropriate care, and that processes are in place to rapidly identify and escalate care needs for deteriorating patients. The ICB continues to monitor compliance with these standards, through daily system calls and discussion with site teams, as well as focused on-site quality visits.”

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 provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.

Verbatim wording from the response
“In addition to the above, the ICB has continued to support provider-level actions to increase oversight of patients in waiting ambulances, enabling collaboration between ambulance and hospital providers to put in place new ways of working to maintain patient safety, that transcend traditional organisational responsibilities. For example, this includes a ‘pit-stop’ assessment model that came into effect at JPUH in June 2022, which enables early diagnostics to be commenced for patients before they enter the ED. This initiative was supported by the use of additional temporary staff including the use of reservists, additional bank staff and medical”

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
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
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
27 Jul2020
Manchester South
Concerns raised1
1. Lack of appropriate Emergency Department space for treating vulnerable patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.
  Stated by Department of Health and Social CareStated completed
1. Action
  Maintain Nightingale Hospitals and their surge capacity.
  Stated by Department of Health and Social CareStated completed
2. Action
  Maintain NHS use of independent-sector hospital capacity.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.
  Stated by Department of Health and Social CareStated planned
4. Action
  Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
5. Action
  Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Samuel Garner · 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

Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

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 appropriate Emergency Department space for treating vulnerable patients
Wider context from the report
“2. As a result of the lack of appropriate space Mr Garner for an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED. This included whilst he was being given antibiotics intravenously - he scored on the sepsis pathway on arrival. He was also moved in and out of bays depending on varying prioritisation of need. ”
Source location
Samuel Garner · 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 rolling out Urgent Treatment Centres, including appointment booking through NHS 111.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Maintain Nightingale Hospitals and their surge capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Maintain NHS use of independent-sector hospital capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.

Verbatim wording from the response
“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complexity care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 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
Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP also has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations, when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 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
Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.

Verbatim wording from the response
“It should be noted that all of the acute trusts in Greater Manchester now utilise a patient safety checklist in their Emergency Departments. These checklists are time-based frameworks that outline clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to help mitigate some of the risks associated with corridor care. These have been adopted from the national checklist template which was published in 2017 and which has been proven to improve clinical processes and reduce harm and serious incidents from unrecognised patient deterioration.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020
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
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
13 Jul2020
Manchester South
Concerns raised1
1. Lack of sufficient emergency department and inpatient bed capacity
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 11
1. Action
  Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.
  Stated by Department of Health and Social CareStated planned
1. Action
  Provide NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.
  Stated by Department of Health and Social CareStated planned
2. Action
  Provide £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.
  Stated by Department of Health and Social CareStated completed
3. Action
  Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.
  Stated by Department of Health and Social CareStated planned
4. Action
  Implement NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
5. Action
  Implement a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
6. Action
  Develop more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
7. Action
  Implement the Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
8. Action
  Create additional community-based capacity to support discharge pathways and improve acute-care patient flow.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

John Cheetham · 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 Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

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 sufficient emergency department and inpatient bed capacity
Wider context from the report
“2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity. The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months. As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED. 3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity. The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed. ”
Source location
John Cheetham · 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 rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 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
Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 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
Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.

Verbatim wording from the response
“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complex care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 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
Provide NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.

Verbatim wording from the response
“NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £300million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 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
Provide £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 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
Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.

Verbatim wording from the response
“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care homes so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 1 October 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
Implement NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 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
Implement a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 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
Develop more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 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
Implement the Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.

Verbatim wording from the response
“Point 3 – hospital bed capacity and the discharge of patients”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 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 additional community-based capacity to support discharge pathways and improve acute-care patient flow.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. As a result, there has been a significant reduction in the proportion of long stay patients and acute hospital bed occupancy levels across all Greater Manchester sites. This has helped to improve flow from Emergency Departments and therefore helped reduce crowding. Bed occupancy is currently on average 83% across Greater Manchester, which is at least 10% lower than the same period last year.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 3 · response
Published 1 October 2020
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
Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 1 · response
Published 1 October 2020
Open published response
28 Jan2019
West London
Concerns raised1
1. Lack of available appropriate examination capacity in the emergency department
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dennis Peter Alfred Warner · 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

Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.

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 available appropriate examination capacity in the emergency department
Wider context from the report
“(1) Mr Warner suffered from advanced dementia and was the main carer for his elderly wife who also suffered with dementia. He was given information about managing his injury on discharge which he was demonstrably unable to comprehend or remember. Specifically, it was recorded by the examining clinicians that he was unable to answer any orientation questions or to remember the reason for his being in hospital. (2) The Emergency department was full beyond capacity and he was examined in a meeting room as no cubicles were available (3) chest xray was performed. I heard in written evidence from ████████ Consultant in Emergency Medicine that chest xray is a suboptimal modality for imaging the chest after injury often underestimating both the number of rib fractures and the extent of any intrathoracic injury(4) there was a delay in senior clinician review of the chest xrays after reporting and a passive approach to contacting Mr Warner was taken by the reviewing clinician. An incorrect number was held for Mr Warner but even if contact had been made then he would have had difficulty comprehending and retaining the information; attempts to contact to contact the GP by phone were abandoned because the phone was not answered. A letter was sent which was described as misleading. Consequently the efforts made to contact and recall the patient were inadequate. ”
Source location
Dennis Peter Alfred Warner · Prevention of Future Deaths report
Page 1 · concerns
Open source report
19 Sep2018
Black Country
Concerns raised1
1. Lack of suitable space or resources for patients awaiting further assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Expand the triage area to increase patient capacity, privacy and dignity.
  Stated by the Dudley Group NHS Foundation TrustStated completed
AI-generated summary

Hubert Kelly · 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

Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.

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 suitable space or resources for patients awaiting further assessment
Wider context from the report
“1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors; 2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area; 3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours. ”
Source location
Hubert Kelly · 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
Expand the triage area to increase patient capacity, privacy and dignity.

Verbatim wording from the response
“The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.”

Source location
Hubert-Kelly-Response
Page 1 · response
Published 19 September 2018
Open published response
24 Dec2015
Norfolk
Concerns raised1
1. Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement and monitor an agreed acute-care pathway with clinician communication channels and a flowchart for detained mental-health patients requiring planned or emergency acute care.
  Stated by James Paget University Hospitals NHS Foundation TrustStated completed
2. Action
  Complete development of a joint referral pathway enabling mental health inpatients to receive timely Emergency Department care through advance notification and agreed arrival times.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completed
3. Action
  Develop local protocols with acute-hospital colleagues for timely, least-distressing assessment of patients with mental health needs and incorporate them into policy.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

CHRISTOPHER JONATHAN HIGGINS · 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

Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

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 an agreed pathway for detained patients requiring assessment and treatment at A & E
Wider context from the report
“(4) There is no agreement in place between the NSFT and the Acute Hospital as to the best way to deal with patients subject to detention under the Mental Health Act who require assessment and treatment at A & E, as a result of which Mr Higgins, was required to wait over 2 hours in a busy, public area, having already self-harmed and shown signs of paranoia. ”
Source location
CHRISTOPHER JONATHAN HIGGINS · 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
Implement and monitor an agreed acute-care pathway with clinician communication channels and a flowchart for detained mental-health patients requiring planned or emergency acute care.

Verbatim wording from the response
“We have considered the issues you raised in your report and we have worked with colleagues at Norfolk and Suffolk Mental Health Trust to develop a process for ensuring that patients under the care of mental health services who require acute care, either planned or as an emergency, have a clear pathway which includes agreed communication channels between clinicians, to expedite that care and reduce any potential for distress. Together we have developed a flow-chart to describe this process which is being used with immediate effect. I have attached a copy of this flow-chart for your information. We will monitor adherence to this new agreed process via the regular operational liaison meetings between our two trusts.”

Source location
2015-0480-Response-by-James-Paget-University-Hospitals-NHS-Trust
Page 1 · response
Published 24 December 2015
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
Complete development of a joint referral pathway enabling mental health inpatients to receive timely Emergency Department care through advance notification and agreed arrival times.

Verbatim wording from the response
“I am writing to apologise that you did not receive a response to the Regulation 28 report following the death of Mr Christopher Higgins within the timeframe set out in your letter of the 24 December 2015. We have been working closely with Norfolk and Suffolk NHS Foundation Trust to develop a referral pathway which will ensure in the future that inpatients from our local mental health facility can access care and treatment in the Emergency Department in a timely manner that limits stress to the individual concerned.”

Source location
2015-0480-Response-by-Queen-Elizabeth-Hospital-NHS-Trust
Page 1 · response
Published 24 December 2015
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 local protocols with acute-hospital colleagues for timely, least-distressing assessment of patients with mental health needs and incorporate them into policy.

Verbatim wording from the response
“In addition to writing to the Trust, you have communicated with the local acute hospitals in Norfolk with the intention of raising to both services the consideration of how patients with mental health needs are cared for in a timely and least distressing way.”

Source location
2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 24 December 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient space for nursing care and pressure-area assessment

Concerns raised1

Reliance on safety checks for patients left in ambulances because of emergency department space delays

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Concerns raised1

Lack of appropriate Emergency Department space for treating vulnerable patients

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of sufficient emergency department and inpatient bed capacity

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 9

Actions described in response 8

Respondent positions 1

Actions described in response 11

Respondent positions 1