Recurring concern

Unreliable hospital bed bureau systems for identifying available beds

First to latest report 19 Nov 2014 — 7 Aug 2015

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 5

What this concern includes

Includes failures of hospital bed-bureau or equivalent bed-identification processes to maintain visibility of available beds, identify beds suitable for patients requiring admission and route or re-route admission requests to the appropriate service, including emergency and child psychiatric admission pathways.

What is not included

Excludes actual shortages or unavailability of hospital beds where no failure of a bed-bureau or bed-identification process is asserted.
Excludes general admission delays, bed placement failures and patient-flow problems where the bed-bureau system itself is not deficient.
Excludes specialist referral, transfer or placement processes that do not involve identifying or routing available hospital beds through a bed-bureau or equivalent system.
Excludes generic information-management, staffing or communication deficiencies without an explicit connection to hospital bed-bureau operation.

Trends

Reports over time

Reports mentioning this concern, 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.

NHS England2

East Midlands Ambulance Service NHS Trust1

NHS Devon Integrated Care Board1

University Hospitals of Leicester NHS Trust1

Reports and published responses 2 reports

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

7 Aug2015
Leicester City and South Leicestershire
Concerns raised1
1. Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

East Midlands Ambulance Service NHS Trust
NHS England
University Hospitals of Leicester NHS Trust
Stated actions 4
1. East Midlands Ambulance Service NHS Trust
  Discuss the additional workforce changes required with lead commissioners to support AMPDS triage for urgent GP and healthcare-professional calls.
2. East Midlands Ambulance Service NHS Trust
  Communicate emergency-response guidance to lead commissioners for dissemination to GPs and Bed Bureau services.
3. University Hospitals of Leicester NHS Trust
  Ensure Bed Bureau staff remain aware of the process for suspected stroke admissions.
1. University Hospitals of Leicester NHS Trust
  Design a Bed Bureau flowchart prompting consideration of emergency admission for suspected stroke patients.
Respondent positions 5
1. East Midlands Ambulance Service NHS Trust
  Bed Bureau call takers cannot override the referring GP’s decision about whether a patient requires emergency admission.
  Redirects responsibility
1. East Midlands Ambulance Service NHS Trust
  Implementing AMPDS triage for all GP and healthcare-professional urgent calls requires additional paramedics; implementation cannot proceed without increased staffing.
  Unable to act
2. University Hospitals of Leicester NHS Trust
  The hospital has a system for identifying GP calls requiring emergency admission, with staff awareness and a flow-chart being added to support that process.
  Existing arrangements considered sufficient
3. University Hospitals of Leicester NHS Trust
  The referring GP remains responsible for identifying when emergency admission is required.
  Redirects responsibility
4. NHS England
  Bed Bureau services are locally organised and guided by the referring GP’s opinion and requirements regarding emergency admission.
  Redirects responsibility
AI-generated summary

George Boulton · 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

George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

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 a bed bureau system for identifying calls requiring emergency admission independently of bed availability
Wider context from the report
“2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission, and not be dependent on a bed, as early scanning was essential for proper diagnosis. ”
Source location
George Boulton · 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
Discuss the additional workforce changes required with lead commissioners to support AMPDS triage for urgent GP and healthcare-professional calls.

Verbatim wording from the response
“In order for EMAS to migrate over to this protocol and using a medical triage system (AMPDS) for all GP urgent and Bed Bureau calls, we will need to uplift the response capability across the region by additional Paramedics.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 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
Communicate emergency-response guidance to lead commissioners for dissemination to GPs and Bed Bureau services.

Verbatim wording from the response
“As this implementation will take some considerable amount of time, as an immediate action we will communicate with our lead commissioners to disseminate the following message to all GP’s and Bed Bureau.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 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
Ensure Bed Bureau staff remain aware of the process for suspected stroke admissions.

Verbatim wording from the response
“Our Head of Capacity and Flow, who manages the Bed Bureau, has identified the written entries that we hold concerning the telephone call received from the patient’s GP, and they indicate that at 15h14 a call was received from the GP who informed our Bed Bureau Call-Handler that she suspected that Mr Boulton was suffering from a stroke and that he was showing right-sided weakness. Our protocol for such patients is for our Bed Bureau staff to invite the GP to consider whether their patient ought properly to be admitted via ED and if so to remind the GP that Bed Bureau staff can only order ambulances on a non-emergency basis which can take up to two hours to arrive. This protocol appears to have been followed in this case.”

Source location
2015-0255-Responses
Page 4 · response
Published 6 July 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
Design a Bed Bureau flowchart prompting consideration of emergency admission for suspected stroke patients.

Verbatim wording from the response
“Since the conclusion of your Investigation, our Head of Capacity and Flow has ensured that all bed bureau staff continue to be aware of the process to be followed should a GP seek to admit a patient via Bed Bureau when a stroke is suspected.”

Source location
2015-0255-Responses
Page 4 · response
Published 6 July 2015
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
Bed Bureau call takers cannot override the referring GP’s decision about whether a patient requires emergency admission.

Verbatim wording from the response
“• The non-medical call taker will ask the caller, “Does the condition present an immediate threat to life?” (I would like to draw your attention to the fact that in common with all other ambulance services our call takers are not clinical, and therefore cannot override a GP or bed bureau decision)”

Source location
2015-0255-Responses
Page 1 · response
Published 6 July 2015
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
Implementing AMPDS triage for all GP and healthcare-professional urgent calls requires additional paramedics; implementation cannot proceed without increased staffing.

Verbatim wording from the response
“Prior to this Prevention of Future deaths (PFD) order being received our senior managers and business intelligence teams have explored the possibility of implementing the AMPDS system to triage all GP and Health Care Professionals (HCP) requests for urgent transport.”

Source location
2015-0255-Responses
Page 2 · response
Published 6 July 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The hospital has a system for identifying GP calls requiring emergency admission, with staff awareness and a flow-chart being added to support that process.

Verbatim wording from the response
“Our Head of Capacity and Flow, who manages the Bed Bureau, has identified the written entries that we hold concerning the telephone call received from the patient’s GP, and they indicate that at 15h14 a call was received from the GP who informed our Bed Bureau Call-Handler that she suspected that Mr Boulton was suffering from a stroke and that he was showing right-sided weakness. Our protocol for such patients is for our Bed Bureau staff to invite the GP to consider whether their patient ought properly to be admitted via ED and if so to remind the GP that Bed Bureau staff can only order ambulances on a non-emergency basis which can take up to two hours to arrive. This protocol appears to have been followed in this case.”

Source location
2015-0255-Responses
Page 4 · response
Published 6 July 2015
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The referring GP remains responsible for identifying when emergency admission is required.

Verbatim wording from the response
“In our view it remains a matter for the GP to identify when emergency admission is required for their patient.”

Source location
2015-0255-Responses
Page 5 · response
Published 6 July 2015
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
Bed Bureau services are locally organised and guided by the referring GP’s opinion and requirements regarding emergency admission.

Verbatim wording from the response
“Bed Bureau Services are local and variable in their organisation; however such services are guided by the opinion and requirements of the referring GP. As stated above, NHS England proposes to engage with GPs through their membership organisations so that all suspected strokes receive a 999 response.”

Source location
2015-0255-Responses
Page 7 · response
Published 6 July 2015
Open published response
19 Nov2014
Exeter & Greater Devon
Concerns raised1
1. Lack of an effective bed bureau system for identifying child psychiatric bed spaces
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

NHS England
Stated actions 1
1. NHS England
  Implement weekly CAMHS bed-capacity reporting and national case-manager teleconferences to support timely identification of available placements.
AI-generated summary

George Christian Werb · 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

George Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child psychiatric beds.

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 effective bed bureau system for identifying child psychiatric bed spaces
Wider context from the report
“(1) The community team had to spend much time making numerous telephone calls to locate a child psychiatric bed. There was not at the time, and still appears to be no, or no effective bed bureau system to identify spaces. This is wasteful of clinician time, creates inevitable delays and is indicative that there are routinely too few available beds to serve the needs of our child psychiatric patients. (2) On a previous admission during May 2014 the bed located was in Hurncombe, and George was removed by his father as the bedroom had inadequate furniture, had no bed linen and there was concern the environment was adding to George’s distress. The distance between home and this placement was in excess of 3 hours travel time. (3) On the index admission, George was placed in the Priory Hospital, Southampton, a distance of over 2 hours travelling time from home. This is not an NHS facility and is specifically for “overflow” patients from all across England, many of whom are therefore huge distances from their home, their family, their friends and community support. (4) Due to the distance, the hospital made the decision that family therapy could not take place (although the parents would have engaged if the importance of this was explained) and periods of home leave were extended due to travelling times, rather than in response to clinical need. (5) There was poor attendance at the CPA meeting, and both parents and the community team only “attended” by telephone, which was far from ideal and impacted on the effectiveness of communication between all parties. (6) Having local accessibility where in patient care is required was recognized in the Mental Health Crisis Care Concordat published 18 February 2014 to be important to keep the young person close to home, school and friends and this was also recognized by all the clinicians at request to be important and necessary. With current provision of beds this need is not being met, and is impacting on patient care. (7) In this case I consider the distance of the unit directly contributed to the circumstances that led to George’s death. ”
Source location
George Christian Werb · 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 weekly CAMHS bed-capacity reporting and national case-manager teleconferences to support timely identification of available placements.

Verbatim wording from the response
“Since August 2013, NHS England has implemented a situation report (SITREP) process each Friday which requires all Child and Adolescent Mental Health Services (CAMHS) inpatient providers to submit numbers of available beds to a national database. This data is used to produce a report that is available from lunch time on a Friday indicating available capacity at each of the inpatient services commissioned. The report is circulated via the Area Teams to all Tier 3/Community CAMHS so they can identify capacity as required and particularly on a Friday when there is often a peak in demand and over the weekend.”

Source location
2014-0510-Response-by-NHS-England
Page 2 · response
Published 19 November 2014
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Lack of an effective bed bureau system for identifying child psychiatric bed spaces

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Stated actions 4

Respondent positions 5

Stated actions 1