Concerns raised 1
Insufficient social care provision for onward discharge support 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
Geoffrey Gordon Fuller · 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
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
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 social care provision for onward discharge support
Wider context from the report “1. The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR) , these being patients who are medically optimised but cannot be discharged due to lack of onward care support .
2. On the day of the ambulance delay, 7 July 2025, almost 20% of patients in RCHT were recorded as NCTR.
3. The court noted the main cause for the numbers of NCTR patients was insufficient social care provision , whether commissioned by social services or NHS.
4. Investigations in 2022 and 2023 by SWAST and the Healthcare Safety Investigation Branch (HSIB) found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found…
“…..there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.”
5. This court has previously noted data indicating significant vacancies in social care posts in Cornwall are vacant reflecting the national picture of nationwide vacant direct social care posts. [see previous PFD reports on this subject]
6. The court noted that the NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market.
7. The HSSIB report referred to the fact that the organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision and support. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage.
8. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm.
” Source location Geoffrey Gordon Fuller · 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 Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.
Verbatim wording from the response “This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.” 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 Work with health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.
Verbatim wording from the response “We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care.” Source location Response from Department of Health and Social Care
Open published response
10 Feb 2026 Barbara Wingate · Prevention of Future Deaths report Kent and Medway
View report summary
Concerns raised 1
Failure to provide timely appropriate community care packages or alternative placements for medically fit patients View source
Linked responses
Kent County Council Medway Council NHS Kent and Medway 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. 19
Kent County Council
Recruit staff and improve referral processes to reduce Kent Enablement at Home discharge times.
View source
Kent County Council
Improve referral processes for the short-term pathway to reduce transfer-of-care times.
View source
Kent County Council
Work with the trust to identify themes and trends causing hospital-discharge delays.
View source
Kent County Council
Review Short Term Pathways practice and processes.
View source
Kent County Council
Review the commissioning of hospital-discharge services.
View source
NHS Kent and Medway Integrated Care Board
Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting to the ICB.
View source
NHS Kent and Medway Integrated Care Board
Increase short-term home-care capacity so more patients can be safely discharged with necessary support.
View source
NHS Kent and Medway Integrated Care Board
Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
View source
NHS Kent and Medway Integrated Care Board
Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
View source
NHS Kent and Medway Integrated Care Board
Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential or nursing placements, with weekly performance reporting to the ICB.
View source
NHS Kent and Medway Integrated Care Board
Increase short-term care-at-home capacity to enable safe discharge with necessary support, overseen through the Medway System Discharge Group.
View source
NHS Kent and Medway Integrated Care Board
Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
View source
NHS Kent and Medway Integrated Care Board
Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
View source
Medway Council
Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.
View source
Medway Council
Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.
View source
Medway Council
Introduce 24-hour care-at-home services for people with high needs to return home safely where appropriate.
View source
Medway Council
Recruit an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.
View source
Medway Council
Establish a dedicated brokerage team to source care for people ready for discharge from hospital or community settings.
View source
Medway Council
Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.
View source See 16 more actions
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AI-generated summary
Barbara Wingate · 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
Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.
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 provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report “Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust . The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged . On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital.
The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement . The evidence suggested that where patients were self funding the delays in discharge were less acute.
This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care . This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients . Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital.
” Source location Barbara Wingate · 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 Recruit staff and improve referral processes to reduce Kent Enablement at Home discharge times.
Verbatim wording from the response “During this period Kent Enablement at Home were experiencing a high number of vacancies within the team, with a 30% vacancy factor which impacted on the referral to discharge time. A recruitment campaign and efficiencies created within referral processes has reduced this time to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48 hour timescale for discharge back to a person’s own home.” Source location Response from Kent County Council
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 Improve referral processes for the short-term pathway to reduce transfer-of-care times.
Verbatim wording from the response “A small number of people are discharged to a short-term bed where they receive a period of enablement and/or assessment of their longer-term care and support needs. The majority of these people are discharged to KCC’s Adult Short Stay Services which are in-house enablement beds. During the time that Mrs Wingate died, the average time for discharge to be facilitated from the time of referral to the Short-Term Pathways team was 5.3 days. Improvements have been made to the referral processes for this pathway, and the current average transfer of care time is 3 days.” Source location Response from Kent County Council
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 Work with the trust to identify themes and trends causing hospital-discharge delays.
Verbatim wording from the response “Despite the improvements made to the length of stay for people with No Criteria to Reside attributable to KCC, our data clearly shows that 50% of referrals experience delays beyond the control of KCC. The main reasons for these delays are availability of discharge documentation, medication, and transport availability. These delays are reported in Medway Hospital’s No” Source location Response from Kent County Council
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 Review Short Term Pathways practice and processes.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
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 Review the commissioning of hospital-discharge services.
Verbatim wording from the response “KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.” Source location Response from Kent County Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting to the ICB.
Verbatim wording from the response “The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.” Source location 2026-0088 - Response from Kent and Medway ICB
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 Increase short-term home-care capacity so more patients can be safely discharged with necessary support.
Verbatim wording from the response “Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:” Source location 2026-0088 - Response from Kent and Medway ICB
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 Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location 2026-0088 - Response from Kent and Medway ICB
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 a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location 2026-0088 - Response from Kent and Medway ICB
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential or nursing placements, with weekly performance reporting to the ICB.
Verbatim wording from the response “The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.” Source location Response from Kent and Medway 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 Increase short-term care-at-home capacity to enable safe discharge with necessary support, overseen through the Medway System Discharge Group.
Verbatim wording from the response “2. Expanding the Home First/short-term support capacity (Pathway 1, Discharge home with short-term support) – capacity for short-term care at home has been increased so more people can leave hospital safely with the necessary support. Oversight of capacity, flow and performance is provided through the Medway System Discharge Group, a local MDT approach supporting discharge.” Source location Response from Kent and Medway 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 Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location Response from Kent and Medway 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 Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
Verbatim wording from the response “3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.” Source location Response from Kent and Medway 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 Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.
Verbatim wording from the response “A range of actions have been implemented or are in progress these are:” Source location Response from Medway Council
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 Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.
Verbatim wording from the response “The Council has commissioned eight assessment beds for individuals ready for discharge but requiring further therapy to support independence before returning home.” Source location Response from Medway Council
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 24-hour care-at-home services for people with high needs to return home safely where appropriate.
Verbatim wording from the response “A range of actions have been implemented or are in progress these are:” Source location Response from Medway Council
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 Recruit an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.
Verbatim wording from the response “The Council has recruited an independent commissioner to work with care providers to understand barriers to accepting discharged patients and to support increased residential and nursing home capacity, particularly for those with complex needs.” Source location Response from Medway Council
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 a dedicated brokerage team to source care for people ready for discharge from hospital or community settings.
Verbatim wording from the response “The Council has established a dedicated brokerage team focused solely on sourcing care for individuals ready to be discharged from hospital or community settings.” Source location Response from Medway Council
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 Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.
Verbatim wording from the response “Medway Council is progressing through governance processes to develop a new 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints” Source location Response from Medway Council
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 Discharge delays cannot be attributed solely to adult social care or community health services because they arise from interdependent system-wide factors.
Verbatim wording from the response “At any given time, it would be erroneous to conclude delays in hospital discharge can be attributed solely to adult social care or community health services. Evidence from across Medway demonstrates that delays arise from a range of interdependent factors across the health and social care system. These include:” Source location Response from Medway Council
Open published response
Concerns raised 1
Limited social care provision affecting patient flow View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Jeremy Miles
Work with the regional partnership board to identify actions addressing local discharge and patient-flow challenges in North Wales.
View source
Jeremy Miles
Allocate £30 million through a new Pathways of Care Transformation Grant to strengthen community social care and support timely discharge.
View source
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AI-generated summary
Angela Frances Darlow · 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
Angela Frances Darlow suffered a stroke at home on 6 January 2025, but an ambulance arrived 23 hours and 20 minutes later. She was diagnosed with an extensive left middle cerebral artery infarct, was not suitable for thrombectomy because of the delay, and died in hospital on 7 June 2025. The principal concern was the prolonged ambulance delay, in the context of high demand, hospital handover delays, patient flow and limited social care provision, resulting in lost opportunities for investigation and potential 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 Limited social care provision affecting patient flow
Wider context from the report “Category of Concern – Emergency Services Related Death; Ambulance Delays (resources)
Angela Darlow was suffering from symptoms of a stroke at home during the afternoon of 6 January 2025. Her husband immediately contacted the Welsh Ambulance Service via 999. Given the significant demand at this time, it took 23 hours and 20 minutes for an emergency ambulance to attend. The calls made to the Trust were correctly categorised. By the time Angela arrived at the nearest hospital, The Countess of Chester, she was outside the time for investigations for thrombectomy.
At the time in question demand was unprecedented. This is reflected by the 23 hour and 20 minute delay in ambulance arriving.
There were significant hospital handover delays at the time which added to the demand on the Trust.
The facts in Angela’s death speak for themselves. I continue to remain concerned about the time is taking for ambulances to arrive in the context of the multifactorial reasons for this which include patient flow in hospitals and limited social care provision . People are dying due to these issues and yet we are no closer to improvement.
” Source location Angela Frances Darlow · 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 Work with the regional partnership board to identify actions addressing local discharge and patient-flow challenges in North Wales.
Verbatim wording from the response “room to make further improvements. The Welsh Government is working with the regional partnership board to identify actions which can be taken to tackle local challenges, such as the trusted assessor models and Discharge to Recover then Assess (D2RA) pathways.” Source location Response from Department for 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 Allocate £30 million through a new Pathways of Care Transformation Grant to strengthen community social care and support timely discharge.
Verbatim wording from the response “To further support discharge and patient flow, we allocated £30m to local authorities via a new Pathways of Care Transformation Grant in 2025-26. Local authorities are using this to support timely discharge and prevent avoidable hospital admissions by strengthening community-based social care.” Source location Response from Department for Health and Social Care
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 Direct delivery of health and social care services is outside Welsh Ministers’ responsibility.
Verbatim wording from the response “Welsh Ministers set the strategic direction for health and care services and hold NHS organisations to account. Welsh Ministers are not responsible for the delivery of health or social care services. Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their respective areas within the national policy framework set by Welsh Ministers.” Source location Response from Department for Health and Social Care
Open published response
10 Jul 2025 Doreen Swann · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of suitable social care placements causing delayed hospital discharges View source
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. 4
NHS Greater Manchester Integrated Care Board
Continue the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.
View source
NHS Greater Manchester Integrated Care Board
Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.
View source
Department of Health and Social Care
Provide £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.
View source
Department of Health and Social Care
Provide over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.
View source See 1 more action
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AI-generated summary
Doreen Swann · 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
Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.
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 social care placements causing delayed hospital discharges
Wider context from the report “1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement . The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive.
2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside.
3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed .
4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department .
” Source location Doreen Swann · 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 the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.
Verbatim wording from the response “As part of a system led improvement programme, there is a continued focus on patient flow and discharge in Tameside covered by the Trust Deputy Chief Operating Officer, Trust Deputy Chief Nurse, and Director of Adult Services for the Local Authority. Progress against the delivery targets within this improvement programme is monitored through a monthly programme group which was established in April 24 and has delivered a significant reduction in patients with a No Criteria to Reside (NCTR) status over recent months. This means that patients who are medically fit for discharge are being discharged to the right place much quicker. This includes process-mapping to support front-door processes to enable deflection to other services.” Source location Response from Greater Manchester Integrated 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 Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.
Verbatim wording from the response “In terms of oversight of discharge planning and patients with NCTR, the Trust’s Chief Operating Officer chairs a weekly meeting to review Length of Stay and Delayed Transfers of Care. Membership includes local stakeholders and the Director of Adult Services to review each patient and ensure appropriateness of care within a hospital setting and aim to support discharge.” Source location Response from Greater Manchester Integrated 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 £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.
Verbatim wording from the response “The Better Care Fund (BCF) is a key part of our plan to address these delays, particularly when they are caused by a shortage of suitable social care, by supporting Integrated Care Boards and local authorities to deliver joined-up health and social care. This year, the BCF will provide £9 billion to help ensure patients receive the right care in the right place, with shared accountability for discharge planning.” 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 over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.
Verbatim wording from the response “Additionally, the Spending Review includes over £4 billion additional funding for adult social care by 2028-29, compared to 2025-26, helping local authorities improve services and meet their duties under the Care Act 2014.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Lack of social care and community hospital capacity for discharge and onward bed availability View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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
Welsh Government
Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.
View source
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AI-generated summary
Jeanette Sidlow Beech · 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
Jeanette Sidlow Beech, who had a history of alcohol withdrawal-related seizures, became unwell at home on 2 August 2024 and died there on 3 August 2024 after suffering a seizure and cardiac arrest. An ambulance took 15 hours and 13 minutes to attend, by which time resuscitation efforts were unsuccessful. The report raises concerns about ambulance response and hospital handover delays, linked to wider pressures involving hospital capacity, social care and community hospital provision.
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 social care and community hospital capacity for discharge and onward bed availability
Wider context from the report “a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful.
b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays.
c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST.
d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons.
e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours . Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours.
f. The issues identified are pertinent to WAST, the Health Board and Local Authorities.
g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists.
” Source location Jeanette Sidlow Beech · 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 Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.
Verbatim wording from the response “We have made an additional £2.7m available to the health board this year to support delivery of local improvement plans. This is part of £35.5m to support the health board and the North Wales Regional Partnership Board to safely manage more people in the community; to avoid ambulance transport and admission to hospital; and deliver integrated solutions with social care services to improve patient flow through hospitals. The impact made by the region is being closely monitored.” Source location Response from Welsh Government
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 Welsh Ministers set strategic expectations but are not responsible for delivering health services.
Verbatim wording from the response “Welsh Ministers set the strategic context and expectations for health and care services in Wales and hold NHS organisations accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.” Source location Response from Welsh Government
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 Health boards are responsible for planning, commissioning and delivering local health services within the national policy framework.
Verbatim wording from the response “Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their local areas, in line with the national policy framework set by Welsh Ministers.” Source location Response from Welsh Government
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 Health boards are responsible for ensuring ambulance handovers occur reliably and that receiving hospitals have sufficient capacity.
Verbatim wording from the response “The Welsh Government’s policy expectation of health boards is that when a patient is conveyed to a hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.” Source location Response from Welsh Government
Open published response
Concerns raised 1
Insufficient social care provision for patients fit for discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department of Health and Social Care
Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.
View source
Department of Health and Social Care
Tackle delayed hospital discharges, beginning with patients staying 21 days beyond their discharge-ready date.
View source
Department of Health and Social Care
Develop local partnership working and increase social care provision to reduce delayed discharges and support timely discharge home.
View source
Department of Health and Social Care
Publish and implement the revised Better Care Fund policy framework prioritising preventative, community-based and integrated health and social care services.
View source
Department of Health and Social Care
Invest £9 billion through the Better Care Fund in integrated health and social care services during 2025/26.
View source See 2 more actions
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AI-generated summary
JAMES FREDERICK SMITH · 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
James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance 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 Insufficient social care provision for patients fit for discharge
Wider context from the report “(1) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge , thereby impeding patient flow through hospital , there being a direct link between inadequate social care provision and ambulance delays.
” Source location JAMES FREDERICK SMITH · 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 Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.
Verbatim wording from the response “But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times:” Source location Response from DHSC
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 Tackle delayed hospital discharges, beginning with patients staying 21 days beyond their discharge-ready date.
Verbatim wording from the response “• tackling the delays in patients waiting to be discharged, starting with those staying 21 days over their discharge-ready-date.” Source location Response from DHSC
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 local partnership working and increase social care provision to reduce delayed discharges and support timely discharge home.
Verbatim wording from the response “We recognise, then, that more needs to be done to develop local partnership working, increase social care provision and tackle delayed discharges to ensure that patients do not remain in hospital when they are well enough to go home.” Source location Response from DHSC
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 Publish and implement the revised Better Care Fund policy framework prioritising preventative, community-based and integrated health and social care services.
Verbatim wording from the response “On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.” Source location Response from DHSC
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 Invest £9 billion through the Better Care Fund in integrated health and social care services during 2025/26.
Verbatim wording from the response “On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.” Source location Response from DHSC
Open published response
9 Apr 2025 Bernard Lyon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of suitable non-acute or community provision for medically optimised patients View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Bernard Lyon · 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
Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.
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 non-acute or community provision for medically optimised patients
Wider context from the report “7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available .
” Source location Bernard Lyon · 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 Publish the revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.
Verbatim wording from the response “More broadly, this government is committed to tackling delayed discharges through the Better Care Fund (BCF), and its revised policy framework, published on 31 January 2025. For 2025-26, approximately £9 billion is committed to the BCF. This includes around £3.3 billion provided to local authorities and £5.6 billion to integrated care boards, both of which” Source location Response from Department of Health and Social Care
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 The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
Verbatim wording from the response “We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect” Source location Response from CQC
Open published response
Concerns raised 1
Insufficient social care provision for patients fit for discharge View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew Waters · 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
Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.
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 social care provision for patients fit for discharge
Wider context from the report “(3) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge , thereby impeding patient flow through hospital .
” Source location Andrew Waters · 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 Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
Verbatim wording from the response “Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.” Source location Response from DHSC
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 Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
Verbatim wording from the response “In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays.” Source location Response from DHSC
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 Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
Verbatim wording from the response “In January 2025, we also published a new policy framework for the £9 billion Better Care Fund. Under the new framework, the NHS and local authorities have clear accountability for setting and achieving joint goals that include reducing discharge delays.” Source location Response from DHSC
Open published response
31 Jan 2025 Nicola Emma OWENS · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 1
Backlog of patients fit for discharge awaiting social care packages 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 England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
View source
Department of Health and Social Care
Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
View source
NHS England
Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
View source
NHS England
Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
View source
NHS England
Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
View source
NHS England
Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
View source See 3 more actions
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AI-generated summary
Nicola Emma OWENS · 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
Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.
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 Backlog of patients fit for discharge awaiting social care packages
Wider context from the report “The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages . Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients.
” Source location Nicola Emma OWENS · 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 Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
Verbatim wording from the response “Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.” Source location Response from DHSC
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 Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
Verbatim wording from the response “We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.” Source location Response from DHSC
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 plans to improve ambulance handovers, response times and urgent and emergency care flow.
Verbatim wording from the response “NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.” Source location Response from NHS England
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 Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
Verbatim wording from the response “NHS England recognises that delayed discharges have a significant impact on hospital flow, capacity and ambulance handovers. In order to address this, NHS England is strengthening the use of Discharge Ready Date (DRD) data in order to gain a clearer understanding of discharge delays and their key contributing factors.” Source location Response from NHS England
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 Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
Verbatim wording from the response “NHS England has also published the 2025/26 Better Care Fund (BCF) policy framework and planning requirements, working alongside the Department of Health and Social Care (DHSC) and Ministry of Housing, Communities and Local Government. The BCF framework supports local systems to jointly agree plans across health and care, including supporting the flow of patients through UEC.” Source location Response from NHS England
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 Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
Verbatim wording from the response “NHS England will be working with local areas to support them to maximise the impact of this investment over the coming year, by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including Local Government Associations, Directors of Social Services, and Care and Health Improvement advisors to support local systems to improve timely discharge of patients.” Source location Response from NHS England
Open published response
2 Dec 2024 Junior George Powell · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1
Lack of suitable community social care delaying discharge of patients ready to leave hospital View source
This report raised 1 other concern. 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
Junior George Powell · 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
Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of death.
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 community social care delaying discharge of patients ready to leave hospital
Wider context from the report “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such patients.
” Source location Junior George Powell · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.