Concerns raised 1
Insufficient space for nursing care and pressure-area assessment View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
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
Open source report
6 Jan 2022 Kyriacos Athanasis · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Reliance on safety checks for patients left in ambulances because of emergency department space delays View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Norfolk and Suffolk Integrated Care Board
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
NHS Norfolk and Suffolk Integrated Care Board
Continue commissioning Hospital Ambulance Liaison Officers across the three acute hospitals to coordinate handover and ambulance turnaround.
View source
NHS Norfolk and Suffolk Integrated Care Board
Implement the ambulance rapid-release protocol across the three acute hospitals for specified clinical circumstances.
View source
NHS Norfolk and Suffolk Integrated Care Board
Coordinate adoption of ambulance-waiting care standards and monitor provider compliance through system calls, site discussions and quality visits.
View source
NHS Norfolk and Suffolk Integrated Care Board
Support provider-level ambulance-waiting safety arrangements, including the JPUH pit-stop assessment model and additional temporary staffing.
View source
Department of Health and Social Care
Deliver six new ambulance hubs to reduce handover delays.
View source
Department of Health and Social Care
Deliver 42 new or upgraded hospital discharge lounges to support safe, timely discharge.
View source
Department of Health and Social Care
Provide 5,000 additional staffed permanent hospital beds.
View source
Department of Health and Social Care
Provide dedicated funding for social care to reduce beds occupied by patients ready for discharge.
View source
Department of Health and Social Care
Establish Same Day Emergency Care services across every hospital with a major emergency department.
View source See 6 more actions
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation 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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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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 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
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 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
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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 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
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 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
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 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
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 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
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 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
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 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
Open published response
27 Jul 2020 Samuel Garner · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of appropriate Emergency Department space for treating vulnerable patients View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department of Health and Social Care
Continue rolling out Urgent Treatment Centres, including appointment booking through NHS 111.
View source
Department of Health and Social Care
Continue implementing Same Day Emergency Care to reduce non-elective hospital admissions.
View source
Department of Health and Social Care
Provide additional funding to alleviate Covid-19 winter pressures and support NHS capacity.
View source
Department of Health and Social Care
Maintain Nightingale Hospitals and their surge capacity.
View source
Department of Health and Social Care
Maintain NHS use of independent-sector hospital capacity.
View source
Department of Health and Social Care
Introduce NHS 111 First to provide low-complexity digital care and direct patients to appropriate settings more quickly.
View source
NHS Greater Manchester Integrated Care Board
Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
View source
NHS Greater Manchester Integrated Care Board
Use patient safety checklists in all Greater Manchester acute-trust emergency departments to support timely assessment and reduce risks from corridor care.
View source See 5 more actions
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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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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 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
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 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
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 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
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 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
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 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
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 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
13 Jul 2020 John Cheetham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of sufficient emergency department and inpatient bed capacity View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 11
Department of Health and Social Care
Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.
View source
Department of Health and Social Care
Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
View source
Department of Health and Social Care
Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.
View source
Department of Health and Social Care
Provide NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.
View source
Department of Health and Social Care
Provide £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.
View source
Department of Health and Social Care
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.
View source
NHS Greater Manchester Integrated Care Board
Implement NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.
View source
NHS Greater Manchester Integrated Care Board
Implement a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.
View source
NHS Greater Manchester Integrated Care Board
Develop more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.
View source
NHS Greater Manchester Integrated Care Board
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.
View source
NHS Greater Manchester Integrated Care Board
Create additional community-based capacity to support discharge pathways and improve acute-care patient flow.
View source See 8 more actions
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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
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
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 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
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
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 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
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 £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
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 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
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 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
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 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
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 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
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 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
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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 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
28 Jan 2019 Dennis Peter Alfred Warner · Prevention of Future Deaths report West London
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Concerns raised 1
Lack of available appropriate examination capacity in the emergency department View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
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.
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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 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
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19 Sep 2018 Hubert Kelly · Prevention of Future Deaths report Black Country
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Concerns raised 1
Lack of suitable space or resources for patients awaiting further assessment 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
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.
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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 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
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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 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
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24 Dec 2015 CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of an agreed pathway for detained patients requiring assessment and treatment at A & E View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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 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
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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 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
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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 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
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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 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.