Recurring concern

Unreliable coordination of social-care-related patient flow

First to latest report 21 Jun 2023 — 10 Jul 2023

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

What this concern includes

Includes failures in the end-to-end coordination process between hospitals, ambulance services and Local Authorities for managing patient flow affected by social-care deficiencies, including unclear or absent Local Authority involvement, inadequate joint working, insufficient progress monitoring and failure to establish or implement a coordinated improvement plan.

What is not included
  • Excludes the existing broader concern concerning insufficient social and community care provision where the assertion is limited to care capacity or provision rather than cross-system coordination of patient flow.
  • Excludes ambulance delays, hospital handover delays or Emergency Department crowding when no social-care-related patient-flow coordination failure is identified.
  • Excludes generic inter-agency communication or governance deficiencies without a material connection to social-care-related patient flow.
  • Excludes failures in individual discharge planning or community-care assessment where the broader cross-system patient-flow coordination condition is not asserted.

Reports and published responses 2 reports

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

  1. North West Wales

    AI-generated summary

    Mary Elizabeth Jones · Prevention of Future Deaths report

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

    Report summary

    Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.

    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

    Failure to involve Local Authorities in considerations of patient flow affected by social care deficiencies

    Wider context from the report

    “This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. ”

    Source location

    Mary Elizabeth Jones · 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

    Seek Welsh Government, NHS and local-government support for clinical risk management across urgent and emergency care pathways to release Trust resources.

    Verbatim wording from the response

    “At this time and in specific response to this Prevention of Future Deaths Report, the Trust does not propose to take any further action or new actions in relation to this matter. The Trust is taking all possible steps within its control to ensure availability of resources to respond to Red and Amber calls. The Trust also seeks to secure full support from Welsh Government, the wider NHS and local government to ensure appropriate clinical risk management across the urgent and emergency care pathways to release resources with the Trust.”

    Source location

    Response from Welsh Ambulance Services NHS Trust
    Page 2 · response
    Published 18 July 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

    Liaise directly with Health Boards and wider health and social care partners to secure support for timely responses to Red and Amber calls.

    Verbatim wording from the response

    “To reaffirm my earlier comment, we believe we have robust plans in place which are regularly critiqued and monitored throughout the organisation. The issues arising are presented to our full Trust Board and we liaise directly with the Health Boards and wider health and social care partners across Wales in order to secure their support to ensure that we respond to Red and Amber calls in a timely way.”

    Source location

    Response from Welsh Ambulance Services NHS Trust
    Page 2 · response
    Published 18 July 2023

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Jean Frickel · 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

    Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

    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 meaningful Local Authority involvement in addressing social-care-related patient-flow deficiencies

    Wider context from the report

    “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following:- 1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and 3. Extent of Strategic plan of action / improvement plan to address the above issues. ”

    Source location

    Jean Frickel · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026