Recurring concern

Failure to provide timely hospital admission

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First reported 13 Dec 2013•Latest report 24 Nov 2025

Definition

What this concern includes

Includes delays or unreliable operation of the end-to-end hospital admission process, including emergency-department handover, patient flow, bed availability, escalation or active management, when these directly prevent or delay admission.

Not included

Excludes delays in a specific treatment or procedure after admission unless they are themselves part of the admission process.
Excludes deficiencies in admission documentation, assessment, communication or review when they do not directly concern whether admission is provided promptly.
Excludes generic staffing, resource or policy deficiencies that are not directly tied to unsafe delay or failure in hospital admission.
Excludes delays or failures in non-hospital placements unless they directly determine whether required hospital admission is provided.

Reports: 47
Individual concerns: 53
Date range: 2013–2025
Stated actions: 176

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care23

Betsi Cadwaladr University LHB10

Welsh Ambulance Services NHS Trust9

NHS England8

Care Quality Commission3

Greater Manchester Health and Social Care Partnership3

Welsh Government3

Ysbyty Gwynedd3

Conwy County Borough Council2

Cwm Taf Morgannwg University Local Health Board2

Denbighshire County Council2

Flintshire County Council2

Greater Manchester Mental Health NHS Foundation Trust2

Health Services Safety Investigations Body2

NHS Greater Manchester Integrated Care Board2

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

24 Nov2025
Surrey
Concerns raised1
1. Requirement for pre-planning before secure mental health unit admission
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.
  Stated by NHS EnglandStated in progress
2. Action
  Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.
  Stated by NHS EnglandStated in progress
3. Action
  Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.
  Stated by NHS EnglandStated completed
AI-generated summary

Diana Ocean Grant · 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

Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.

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
Requirement for pre-planning before secure mental health unit admission
Wider context from the report
“The concern arises in relation to persons who are judged to need immediate admission to a mental health unit for assessment and/or treatment, but who are also judged to need admission to a secure unit because they are dangerous to others, whether by reason of being under arrest for, or charged with, a serious criminal offence or otherwise. The evidence I received established that, despite changes made since the Deceased’s death, including the recent introduction of NHS England’s “Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification”, it remains extremely unlikely that such a person will be granted immediate admission to a secure mental health unit. This is principally because of the restricted capacity of the secure mental health unit estate, but also because of an expectation that some element of pre-planning will take place before such an admission occurs. Consequently, for many persons in the circumstances described above, detention in prison prior to transfer to a secure mental health unit continues to be unavoidable. The evidence I heard at the inquest suggested that although the expectation, in those circumstances, is that transfer from prison to hospital should take place within 28 days, the low availability of beds actually results in transfers taking, on average, as long as 80 to 90 days. Detention in prison of persons requiring mental health unit admission raises a concern for risk of death. The evidence I heard established that this is because a mental health patient’s needs cannot be fully met in prison, even in a prison’s health care wing. This is by reason of the fact that there is a material difference in the physical environment, the nursing and therapeutic regimes, and the access to psychological and other therapeutic treatments. Further, whilst medication and treatment can be given compulsorily in hospital, that is not the case in prison. The witness from whom I heard, stated that he was not aware of any work or review currently being undertaken to address the lack of capacity within the secure mental health unit estate or to address how the above risk may be resolved or managed. ”
Source location
Diana Ocean Grant · Prevention of Future Deaths report
Page 6 · 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
Map emergency admission arrangements across adult forensic provider collaboratives, including out-of-hours access.

Verbatim wording from the response
“NHS England’s Adult Forensic Services Team are currently mapping arrangements across all 15 Adult Secure Provider Collaboratives for emergency admissions to an adult forensic bed, including out of hours, to understand variation across England.”

Source location
Response from NHS England
Page 3 · response
Published 1 December 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a national adult forensic Access Assessment Services specification requiring emergency adult forensic bed admission arrangements, including out-of-hours access.

Verbatim wording from the response
“Using this information, and in collaboration with relevant stakeholders, we are developing a new national service specification for Access Assessment Services (for adult forensic services), that will include a requirement that arrangements are in place for emergency admissions to an adult forensic bed, including out of hours.”

Source location
Response from NHS England
Page 3 · response
Published 1 December 2025
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
Launch and maintain a national database of adult forensic Access Assessment Services with referral and out-of-hours contact information.

Verbatim wording from the response
“We have also created a database of Access Assessment Services (for adult forensic services) across England, that includes the direct contact information for referrals and urgent referrals, and out of hours contact information. This has now been launched and is accessible via the NHS Futures Collaboration Platform.”

Source location
Response from NHS England
Page 3 · response
Published 1 December 2025
Open published response
4 Aug2025
Surrey
Concerns raised1
1. Lack of psychiatric hospital beds resulting in prolonged emergency department detention
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Increase the number of funded inpatient mental health beds for the Trust’s population.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
2. Action
  Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
3. Action
  Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
1. Action
  Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
2. Action
  Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.
  Stated by NHS Southwest London Integrated Care BoardStated in progress
3. Action
  Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.
  Stated by NHS Southwest London Integrated Care BoardStated in progress
4. Action
  Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.
  Stated by NHS Southwest London Integrated Care BoardStated planned
Respondent positions 5
1. Position
  Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
  Stated by Epsom and St Helier University Hospitals NHS TrustOutside remit
1. Position
  Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
  Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibility
2. Position
  Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
  Stated by Department of Health and Social CareRedirects responsibility
3. Position
  Surrey patients’ psychiatric beds are commissioned by Surrey Heartlands ICB from Surrey and Borders Partnership NHS Foundation Trust.
  Stated by NHS Southwest London Integrated Care BoardRedirects responsibility
4. Position
  Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Tracey Ostler · 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

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital 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 psychiatric hospital beds resulting in prolonged emergency department detention
Wider context from the report
“Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care 1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed. 2. I remain concerned that there in no plan to stop this practice and that therefore: a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team. b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients. c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients. d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician. e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area. f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. ”
Source location
Tracey Ostler · Prevention of Future Deaths report
Page 4 · 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
Increase the number of funded inpatient mental health beds for the Trust’s population.

Verbatim wording from the response
“The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 1 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue improving service flow, aligning operational processes and reducing unnecessary inpatient delays and length of stay.

Verbatim wording from the response
“The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 1 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue the Mind and Body Provider Collaborative improvement programme with acute care partners, using clinical, escalation and risk-management frameworks.

Verbatim wording from the response
“Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.”

Source location
Response from NHS Surrey and Borders Partnership NHS Foundation Trust
Page 1 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide daily escalation and weekly executive oversight of patients awaiting psychiatric admission through collaboration with SABP and the ICB.

Verbatim wording from the response
“The Trust works collaboratively with SABP to ensure that these delays are kept to a minimum. Every patient awaiting psychiatric admission is subject to daily escalation through Trust site meetings and concerns are raised with SABP and the ICB. Executive led weekly meetings between the Trust and SABP provides further oversight of plans for mental health patients at the Trust. The Trust continues to advocate for timely transfer to inpatient psychiatric units recognising that ED cannot provide the ward-based, multidisciplinary care these patients require.”

Source location
Response from Epsom General Hospital
Page 3 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain regular cross-boundary system calls and agreed escalation arrangements between Epsom General Hospital and mental health providers.

Verbatim wording from the response
“The cross-boundary arrangement at EGH requires coordination between the two mental health providers (SABP and SWLStG) and the two commissioners (SW London ICB and Surrey & Borders ICB). Routine actions underway include regular system calls and agreed escalation arrangements between EGH and mental health providers.”

Source location
Response from NHS South West London Integrated Care Board
Page 3 · response
Published 13 August 2025
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
Work with the commissioned mental health trust to improve the urgent care pathway, maximise appropriate crisis alternatives, and reduce delays in accessing inpatient beds.

Verbatim wording from the response
“SW London works closely with SWLSTG to address delays in the urgent care pathway and minimise delays in access to beds. This work is focused on both improving the inpatient pathway and maximising use of crisis alternatives where appropriate and able to meet patient needs. Such services include the 24/7 crisis lines, ‘111 press 2 for mental health service’, community-based crisis cafés, and Home Treatment Teams.”

Source location
Response from NHS South West London Integrated Care Board
Page 3 · response
Published 13 August 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use the assessment outputs to identify pathway gaps, support future commissioning and winter planning, and produce tailored improvement plans for mental healthcare delivery.

Verbatim wording from the response
“The outputs of this work will identify gaps within current pathways and support future commissioning plans, including winter planning. It will also provide tailored improvement plans aimed at enhancing mental healthcare delivery within SWLSTG and reducing demand and delays in emergency departments across SW London.”

Source location
Response from NHS South West London Integrated Care Board
Page 3 · response
Published 13 August 2025
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
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.

Verbatim wording from the response
“Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 2025
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
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.

Verbatim wording from the response
“NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.”

Source location
Response from Epsom General Hospital
Page 2 · response
Published 13 August 2025
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
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.

Verbatim wording from the response
“We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.”

Source location
Response from Department for Health and Social Care
Page 1 · response
Published 13 August 2025
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
Surrey patients’ psychiatric beds are commissioned by Surrey Heartlands ICB from Surrey and Borders Partnership NHS Foundation Trust.

Verbatim wording from the response
“Psychiatric beds for patients who require inpatient care and present at the emergency department at Epsom General Hospital (EGH) are commissioned separately depending on GP registration. SW London patients are admitted to South West London & St George’s NHS Mental Health Trust (SWLStG), commissioned by SW London ICB. Surrey patients are admitted to Surrey and Borders Partnership NHS Foundation Trust (SABP), commissioned by Surrey Heartlands ICB.”

Source location
Response from NHS South West London Integrated Care Board
Page 3 · response
Published 13 August 2025
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
Individual trusts and local health systems are responsible for assessing and managing local psychiatric bed capacity.

Verbatim wording from the response
“We expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.”

Source location
Response from Department for Health and Social Care
Page 1 · response
Published 13 August 2025
Open published response
2 Jul2025
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to establish an appropriate admission pathway for worsening patients in the renal unit
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and publish a clinical guideline defining the pathway for deteriorating patients on the renal unit.
  Stated by Royal Cornwall Hospitals NHS TrustStated completed
AI-generated summary

JASON JAMES CLEMENS · 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

Jason James Clemens died on 23 March 2024 after a seven-hour delay in administering antibiotics prescribed for immediate use following a medical episode at the renal unit. The report identified four missed opportunities to administer the antibiotics and stated that the delay likely hastened his death and more than minimally contributed to his cause of death. It also raised concerns about the absence of implemented procedures for managing worsening renal-unit patients and uncertainty about the appropriate admission pathway.

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 establish an appropriate admission pathway for worsening patients in the renal unit
Wider context from the report
“The hospital accepted that there were failings that contributed to Jason’s death. Measures to address those failings had not been fully implemented at the date of the Inquest. There were no applicable standard operating procedures for worsening patients in the renal unit at the date of Jason’s death and none had been implemented by the date of the inquest. Jason died on 23 March 2024. The inquest was held on 5 June 2025. The court was told that the standard operating procedures are still being drafted in relation to identifying the appropriate pathway for the admission of worsening patients in the renal unit. The clinicians were undecided on applicable processes including whether the emergency department should be the default pathway. The court found on the evidence that moving worsening patients out of the renal unit and onto in-patient facilities is imperative and should be done at the first available opportunity. Such action would reduce the risks of medication and treatment errors and delays such as that which occurred in Jason’s case. Delays due to uncertainties about appropriate pathways raises risks to patients who require the specialist treatment available on in-patient facilities. ”
Source location
JASON JAMES CLEMENS · Prevention of Future Deaths report
Page 3 · 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
Develop and publish a clinical guideline defining the pathway for deteriorating patients on the renal unit.

Verbatim wording from the response
“A Clinical Guideline has been developed to assist staff on the Renal Unit to regarding the relevant pathway a patient should follow, should they become unwell or deteriorate on the Renal Unit. This has been shared with staff and has been uploaded on the Trust’s internal Intranet page for all staff members to review and have access to. A copy of the Clinical Guideline is attached to this response as ‘Enclosure 2’.”

Source location
Response from Royal Cornwall Hospitals
Page 2 · response
Published 15 July 2025
Open published response
19 Feb2025
Manchester South
Concerns raised3
1. Insufficient availability of ward beds for Emergency Department patient flow
2. Prolonged waits in Emergency Departments for ward beds
3. Recurring prolonged waits in Emergency Departments for ward beds
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Publish the 2025 NHS mandate and planning guidance containing urgent-care delivery priorities and implementation targets.
  Stated by Department of Health and Social CareStated completed
2. Action
  Continue improving urgent and emergency care services to improve access and restore constitutional waiting-time performance.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Kenneth James CLAYTON · 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

Kenneth James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.

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 availability of ward beds for Emergency Department patient flow
Wider context from the report
“3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Prolonged waits in Emergency Departments for ward beds
Wider context from the report
“1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Recurring prolonged waits in Emergency Departments for ward beds
Wider context from the report
“2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual. As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 1 · 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
Publish the 2025 NHS mandate and planning guidance containing urgent-care delivery priorities and implementation targets.

Verbatim wording from the response
“On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026.”

Source location
Response from DHSC
Page 2 · response
Published 21 February 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue improving urgent and emergency care services to improve access and restore constitutional waiting-time performance.

Verbatim wording from the response
“The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. I would like to assure you we are committed to continuing to improve services to ensure patients can access the right care first time, only visiting A&E when necessary, and returning waiting times to the NHS constitutional standard where at least 95% of patients in A&E will be admitted, transferred or discharged within 4 hours.”

Source location
Response from DHSC
Page 1 · response
Published 21 February 2025
Open published response
4 Feb2025
North East Kent
Concerns raised2
1. Delays in emergency treatment caused by unavailable inpatient beds
2. Failure to free hospital beds occupied by patients medically fit for discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Increase same-day emergency care so more patients are seen, treated and discharged within one day.
  Stated by Department of Health and Social CareStated planned
2. Action
  Increase the proportion of patients discharged by or on day seven of admission.
  Stated by Department of Health and Social CareStated planned
3. Action
  Develop local NHS and social-care partnerships to reduce delayed discharges and patients waiting to leave hospital.
  Stated by Department of Health and Social CareStated planned
1. Action
  Continue operating-model work with regions to support providers in reducing Emergency Department crowding.
  Stated by NHS EnglandStated in progress
2. Action
  Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.
  Stated by NHS EnglandStated completed
3. Action
  Strengthen use of Discharge Ready Date and Reason for Discharge Delay data to identify and reduce discharge delays.
  Stated by NHS EnglandStated in progress
4. Action
  Work with local areas and health, social care and local-government partners to maximise discharge-funding impact and improve timely patient discharge.
  Stated by NHS EnglandStated in progress
5. Action
  Collect daily data on patients experiencing long Emergency Department waits and track actions to support appropriate accommodation and patient-safety review.
  Stated by NHS EnglandStated in progress
6. Action
  Collect weekly data on patients waiting over 100 days for discharge and use system leadership, coordination calls and regional engagement to enable appropriate discharge.
  Stated by NHS EnglandStated in progress
7. Action
  Reform the Better Care Fund so pooled NHS and local-authority funding supports reducing emergency admissions, delayed discharges and care-home admissions.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Dorothy Lilian REID · 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

Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.

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
Delays in emergency treatment caused by unavailable inpatient beds
Wider context from the report
“(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem. ”
Source location
Dorothy Lilian REID · Prevention of Future Deaths report
Page 3 · concerns
Open source report
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 free hospital beds occupied by patients medically fit for discharge
Wider context from the report
“(2) Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem. ”
Source location
Dorothy Lilian REID · Prevention of Future Deaths report
Page 3 · 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
Increase same-day emergency care so more patients are seen, treated and discharged within one day.

Verbatim wording from the response
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
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
Increase the proportion of patients discharged by or on day seven of admission.

Verbatim wording from the response
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26:”

Source location
Response from DHSC
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop local NHS and social-care partnerships to reduce delayed discharges and patients waiting to leave hospital.

Verbatim wording from the response
“Regarding the concern raised about bed capacity and 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
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue operating-model work with regions to support providers in reducing Emergency Department crowding.

Verbatim wording from the response
“NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 1 · response
Published 7 February 2025
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
Issue operational planning guidance requiring systems to improve patient flow through alternative urgent and emergency care services.

Verbatim wording from the response
“NHS England will continue to work through the operating model and assist its Regions with supporting providers to reduce crowding in EDs. In the longer term, NHS England hopes to eliminate this by focusing on reducing the number of patients that wait longer than 12 hours in EDs. Improvements are being demonstrated through NHS England’s operational planning guidance, where systems were asked to focus on areas to deliver improved patient flow such as increasing the proportion of patients streamed to alternative services such as urgent treatment centres (UTCs), same day emergency care (SDEC) and acute frailty services (AFS). This includes increasing the productivity of acute and non-acute hospital services, improving flow as well as clinical outcomes.”

Source location
Response from NHS England
Page 1 · response
Published 7 February 2025
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
Strengthen use of Discharge Ready Date and Reason for Discharge Delay data to identify and reduce discharge delays.

Verbatim wording from the response
“NHS England recognises the significant impact that delayed discharges have on hospital flow, ambulance handovers and the patients affected by these delays. To address this, we are strengthening the use of Discharge Ready Date (DRD) and Reason for Discharge Delay (RfDD) data to gain a clearer understanding of discharge delays and their key contributing factors, both locally and nationally, so that measures can be taken to reduce the number of patients occupying beds who are ready for discharge.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Work with local areas and health, social care and local-government partners to maximise discharge-funding impact and improve timely patient discharge.

Verbatim wording from the response
“Over the coming year we will be working with local areas to support them to maximise the impact of this investment, for example by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including the Local Government Association (LGA), Directors of Social Services (DASSs) and Care and Health Improvement Advisers (CHIAs) to support local systems to improve timely discharge of patients.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Collect daily data on patients experiencing long Emergency Department waits and track actions to support appropriate accommodation and patient-safety review.

Verbatim wording from the response
“NHS England has commenced a data collection of patients experiencing long waits in Emergency Departments on a daily basis and will ensure actions are in place to appropriately accommodate these patients as soon as possible. The data is discussed at the National Coordination Centre call, with actions tracked to ensure executive oversight and assurance as well as patient safety and harm reviews of/for patients waiting.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Collect weekly data on patients waiting over 100 days for discharge and use system leadership, coordination calls and regional engagement to enable appropriate discharge.

Verbatim wording from the response
“In addition, to reduce the number of very long discharge waits, we have been collecting weekly data to identify the number of patients waiting over 100 days and will ensure actions are being taken through system leadership to enable patients to be discharged to the most appropriate setting as soon as possible. The patients identified as waiting over 100 days will be discussed at a weekly National Coordination Centre call, and themes will be tracked through weekly regional engagement meetings.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
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
Reform the Better Care Fund so pooled NHS and local-authority funding supports reducing 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
Page 2 · response
Published 7 February 2025
Open published response
24 Nov2024
East Riding and Hull
Concerns raised1
1. Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 15
1. Action
  Implement the phased 045 Handover Plan to reduce ambulance handover times toward a 45-minute target.
  Stated by NHS Humber Health PartnershipStated completed
2. Action
  Activate the Ambulance Delay Protocol, including site escalation, rapid patient transfers, and prioritisation of suitable patients.
  Stated by NHS Humber Health PartnershipStated completed
3. Action
  Revise the operating procedure to offload up to eight ambulances hourly and transfer ten patients from the Emergency Department to inpatient wards.
  Stated by NHS Humber Health PartnershipStated in progress
1. Action
  Implement Pull for Safety to maintain regular patient flow from the Emergency Department to assessment areas and wards.
  Stated by NHS Humber Health PartnershipStated completed
2. Action
  Use escalation areas and reverse boarding protocols to create immediate capacity for arriving patients.
  Stated by NHS Humber Health PartnershipStated completed
3. Action
  Implement the Temporary Escalation Space and Boarding SOP to manage capacity challenges, patient boarding, and timely Emergency Department handovers.
  Stated by NHS Humber Health PartnershipStated completed
4. Action
  Open and operate a 54-bed NCTR unit to accommodate patients awaiting discharge and reduce reliance on acute beds.
  Stated by NHS Humber Health PartnershipStated completed
5. Action
  Implement updated discharge protocols covering local-authority coordination, family and carer involvement, and care transfer hubs.
  Stated by NHS Humber Health PartnershipStated completed
6. Action
  Conduct board rounds and huddles to identify discharges early and meet ward discharge targets of 30% by noon and 70% by 17:00.
  Stated by NHS Humber Health PartnershipStated completed
7. Action
  Enforce maximum stays of 24 hours in AMU and 12 hours in the Emergency Department to maintain patient flow.
  Stated by NHS Humber Health PartnershipStated completed
8. Action
  Monitor ambulance arrivals and Emergency Department capacity in real time and escalate boarding or discharge issues through clinical and senior leadership.
  Stated by NHS Humber Health PartnershipStated completed
9. Action
  Continue working with trusts and services facing significant ambulance handover challenges.
  Stated by NHS EnglandStated in progress
10. Action
  Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.
  Stated by NHS EnglandStated planned
11. Action
  Prioritise reducing delays in urgent and emergency care pathways.
  Stated by NHS EnglandStated planned
12. Action
  Prioritise improving length of stay in NHS-commissioned community beds.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  Local and system concerns fall outside NHS England’s national policy and programme remit.
  Stated by NHS EnglandOutside remit
1. Position
  Local organisations should address the local and system concerns raised in the report.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Colin Wiles · 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

Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost 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
Inability to hand over emergency ambulance patients into the emergency department at Hull Royal Infirmary
Wider context from the report
“(4) There appears to be an issue with no criteria to reside patients and the ability to hand over patients into ED in Hull Royal Infirmary who arrive in emergency ambulances. ”
Source location
Colin Wiles · Prevention of Future Deaths report
Page 3 · 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 the phased 045 Handover Plan to reduce ambulance handover times toward a 45-minute target.

Verbatim wording from the response
“On 9th December 2023, we implemented the 045 Handover Plan at Hull Royal Infirmary, which involves a phased approach to reduce ambulance handover times:”

Source location
Response from NHS Humber Health Partnership
Page 1 · response
Published 2 December 2024
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
Activate the Ambulance Delay Protocol, including site escalation, rapid patient transfers, and prioritisation of suitable patients.

Verbatim wording from the response
“1. Ambulance Delay Protocol Activation: The Ambulance Delay Protocol mandates that ambulance patients should be handed over within 15 minutes of arrival, with no patient waiting longer than 60 minutes. If a delay exceeds 45 minutes with no immediate plan to hand over, the protocol is triggered, requiring:”

Source location
Response from NHS Humber Health Partnership
Page 1 · response
Published 2 December 2024
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
Revise the operating procedure to offload up to eight ambulances hourly and transfer ten patients from the Emergency Department to inpatient wards.

Verbatim wording from the response
“3. Proactive Patient Flow Management:”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement Pull for Safety to maintain regular patient flow from the Emergency Department to assessment areas and wards.

Verbatim wording from the response
“• Implementing the Pull for Safety process, which establishes a regular patient flow from the ED to assessment areas and wards.”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use escalation areas and reverse boarding protocols to create immediate capacity for arriving patients.

Verbatim wording from the response
“• Utilising escalation areas and reverse boarding protocols to create immediate capacity for new arrivals, as detailed in the policy.”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement the Temporary Escalation Space and Boarding SOP to manage capacity challenges, patient boarding, and timely Emergency Department handovers.

Verbatim wording from the response
“Between March and April 2023, 20–25% of the Trust's bed base (approximately 180 beds, equivalent to six wards) was occupied by NCTR patients on discharge pathways 1–3. This occupancy severely impacted patient flow and the availability of beds for incoming ED patients. In response, the Trust has undertaken a series of strategic measures to alleviate these pressures. In November 2024 the Trust implemented the Temporary Escalation Space (TES) and Boarding SOP, which provides a framework for managing capacity challenges and improving flow.”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
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
Open and operate a 54-bed NCTR unit to accommodate patients awaiting discharge and reduce reliance on acute beds.

Verbatim wording from the response
“1. Creation of Additional Capacity:”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement updated discharge protocols covering local-authority coordination, family and carer involvement, and care transfer hubs.

Verbatim wording from the response
“2. Formal Discharge and Flow Improvements:”

Source location
Response from NHS Humber Health Partnership
Page 2 · response
Published 2 December 2024
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
Conduct board rounds and huddles to identify discharges early and meet ward discharge targets of 30% by noon and 70% by 17:00.

Verbatim wording from the response
“• Boarding Protocols: The SOP outlines structured boarding processes to manage NCTR patients effectively and create capacity in the ED. This includes: - Identifying and moving up to three patients per ward to temporary escalation spaces (TES) or discharge lounges within 30 minutes. - Ensuring timely handovers from ED to inpatient wards to free up ED spaces.”

Source location
Response from NHS Humber Health Partnership
Page 3 · response
Published 2 December 2024
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
Enforce maximum stays of 24 hours in AMU and 12 hours in the Emergency Department to maintain patient flow.

Verbatim wording from the response
“3. Operational Measures from the TES and Boarding SOP:”

Source location
Response from NHS Humber Health Partnership
Page 3 · response
Published 2 December 2024
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
Monitor ambulance arrivals and Emergency Department capacity in real time and escalate boarding or discharge issues through clinical and senior leadership.

Verbatim wording from the response
“4. Senior Oversight and Escalation:”

Source location
Response from NHS Humber Health Partnership
Page 3 · response
Published 2 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with trusts and services facing significant ambulance handover challenges.

Verbatim wording from the response
“the community. NHS England are continuing to work with trusts and services with significant handover challenges at the ‘front end’, alongside recognising the importance of reducing length of stay and timely discharge to maintain adequate patient flow and allow new patients to be handed over more promptly to EDs.”

Source location
Response from NHS England
Page 2 · response
Published 2 December 2024
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
Prioritise improving length of stay for admitted patients, particularly emergency admissions lasting at least one day.

Verbatim wording from the response
“NHS England will also be prioritising:”

Source location
Response from NHS England
Page 3 · response
Published 2 December 2024
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
Prioritise reducing delays in urgent and emergency care pathways.

Verbatim wording from the response
“NHS England will also be prioritising:”

Source location
Response from NHS England
Page 3 · response
Published 2 December 2024
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
Prioritise improving length of stay in NHS-commissioned community beds.

Verbatim wording from the response
“NHS England will also be prioritising:”

Source location
Response from NHS England
Page 3 · response
Published 2 December 2024
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
Local and system concerns fall outside NHS England’s national policy and programme remit.

Verbatim wording from the response
“My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
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
Local organisations should address the local and system concerns raised in the report.

Verbatim wording from the response
“My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy and programme remit. It is appropriate for the other organisations you have addressed your Report to, Hull University Teaching Hospitals NHS Trust and East Riding of Yorkshire Council Adult Social Care and Health, to address the local and system concerns you raise.”

Source location
Response from NHS England
Page 1 · response
Published 2 December 2024
Open published response
24 Sep2024
Manchester South
Concerns raised1
1. Unavailability of acute beds causing delays in allocating beds to patients requiring admission
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue reviewing discharge processes, alternatives to hospital admission, and patient-flow pathways across Greater Manchester hospitals.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
AI-generated summary

George Neville Coulthard · 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 Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.

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
Unavailability of acute beds causing delays in allocating beds to patients requiring admission
Wider context from the report
“1. Mr Coulthard was assessed as being suitable for discharge on 18th December. He remained in an acute hospital setting for a further 4 weeks due to challenges in identifying a suitable care home. This was due to the inquest was told to a shortage of suitable places and the Christmas period. The impact of this on Mr Coulthard was that he remained in an acute setting when the inquest was told the care he required would have been better delivered in a care home /nursing home setting. In addition the inquest heard evidence that it meant that an acute bed required for other patients was not available creating delays in allocating beds to patients requiring admission. The inquest was told that significant delays of this nature occur on a regular basis and are often exacerbated over the Christmas period. ”
Source location
George Neville Coulthard · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue reviewing discharge processes, alternatives to hospital admission, and patient-flow pathways across Greater Manchester hospitals.

Verbatim wording from the response
“You refer to such delays occurring on a regular basis and often exacerbated by the festive period. The winter period generally is extremely busy with high numbers of patients entering the hospital and needing to be admitted for care and treatment. Whilst every effort is made to appropriately manage the flow of patients to free up beds, there are occasions when delays in discharge do impact on patient flow. This is regrettably not a scenario that is specific to the festive period as such challenges occur throughout the year, but particularly through the winter months. As a system we consistently review discharge processes, alternatives to hospital admission, and patient flow pathways. This is with a view to improving the patient experience and flow through all GM hospitals so that patients can receive the right care at the right time and in the right place.”

Source location
Response from GMIC
Page 4 · response
Published 24 September 2024
Open published response
20 Sep2024
Berkshire
Concerns raised1
1. Delays in hospital handover of ambulance patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Improve hospital flow to reduce unnecessary hospital stays and delayed discharges.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Develop local NHS and social-care partnership working to tackle delayed discharges.
  Stated by Department of Health and Social CareStated planned
3. Action
  Ensure every acute hospital has access to a care transfer hub for complex discharges.
  Stated by Department of Health and Social CareStated completed
1. Action
  Work directly with health and social-care partners in systems facing the most discharge delays to drive improvements.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Improve hospital patient flow and reduce ambulance handover delays through discharge and provider-coordination measures.
  Stated by NHS EnglandStated in progress
3. Action
  Use Key Lines of Enquiry to help ambulance and acute providers identify opportunities to reduce handover delays and improve patient flow.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  Responsibility for addressing ongoing handover delays rests with the responsible integrated care boards commissioning the hospital emergency department services.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Susan Dear · 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

Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.

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
Delays in hospital handover of ambulance patients
Wider context from the report
“(6) handover delays at the Royal Berkshire Hospital and the Wexham Park Hospital were found to be a substantial root cause of the problem (due to ambulance staff being delayed at hospital with patients who could not be admitted to Accident & Emergency as other patients were unable to be admitted to the wards until beds were available) and that this was a problem that required improvement at a national level with changes to the social care system to ease the discharge of patients who required care in the community from the wards back into the community; and ”
Source location
Susan Dear · 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
Improve hospital flow to reduce unnecessary hospital stays and delayed discharges.

Verbatim wording from the response
“Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop local NHS and social-care partnership working to tackle delayed discharges.

Verbatim wording from the response
“Turning to your concerns on ambulance handover delays, this government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care – and making sure people get the right support from health and social care services to return home as soon as possible.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 2024
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 every acute hospital has access to a care transfer hub for complex discharges.

Verbatim wording from the response
“We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 2024
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
Work directly with health and social-care partners in systems facing the most discharge delays to drive improvements.

Verbatim wording from the response
“We have also ensured that every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support. In the integrated care systems that face the most discharge delays, the Department is working directly with partners across health and social care to drive improvements.”

Source location
Response from DHSC
Page 2 · response
Published 14 November 2024
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
Improve hospital patient flow and reduce ambulance handover delays through discharge and provider-coordination measures.

Verbatim wording from the response
“Work has also focused on the need to increase ambulance capacity through growing the workforce, improving flow through hospitals and reducing handover delays, speeding up discharges from hospital and expanding new services in the community; all of which support improved patient flow. The NHS is also working more closely with local authorities to improve the timely discharge of patients and has developed discharge metrics to monitor performance improvements.”

Source location
Response from NHSE
Page 1 · response
Published 14 November 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use Key Lines of Enquiry to help ambulance and acute providers identify opportunities to reduce handover delays and improve patient flow.

Verbatim wording from the response
“Within Emergency Departments, the NHS standard contract states that all handovers of patients between ambulances and A&E must take place within 15 minutes, with none taking more than 30 minutes. The clock begins when an ambulance arrives outside an A&E department and stops when a clinical handover has been fully completed to A&E staff. Key Lines of Enquiry (KLOEs) have previously been developed by NHS England to support ambulance and acute providers to identify key opportunities to reduce ambulance handover delays and improve patient flow, as outlined in the UEC Recovery Plan (2023).”

Source location
Response from NHSE
Page 2 · response
Published 14 November 2024
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
Responsibility for addressing ongoing handover delays rests with the responsible integrated care boards commissioning the hospital emergency department services.

Verbatim wording from the response
“My regional colleagues are also in the process of engaging with Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (BOB ICB) and Frimley ICB,”

Source location
Response from NHSE
Page 2 · response
Published 14 November 2024
Open published response
6 Sep2024
Manchester South
Concerns raised1
1. Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.
  Stated by Care Quality CommissionOutside remit
1. Position
  Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.
  Stated by Care Quality CommissionRedirects responsibility
AI-generated summary

John Francis HOWLETT · Prevention of Future Deaths report

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

Report summary

John Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.

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 move patients from emergency departments onto wards in a timely manner due to capacity constraints
Wider context from the report
“1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues. The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time. ”
Source location
John Francis HOWLETT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.

Verbatim wording from the response
“We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We 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.”

Source location
Response from CQC
Page 4 · response
Published 10 September 2024
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
Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.

Verbatim wording from the response
“We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We 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.”

Source location
Response from CQC
Page 4 · response
Published 10 September 2024
Open published response
31 May2024
Dorset
Concerns raised1
1. Delays in transferring prisoners requiring mental health hospital admission
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.
  Stated by Department of Health and Social CareStated planned
3. Action
  Introduce the Mental Health Bill during the current Parliamentary session.
  Stated by Department of Health and Social CareStated planned
1. Action
  Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.
  Stated by NHS EnglandStated in progress
2. Action
  Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.
  Stated by NHS EnglandStated completed
3. Action
  Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.
  Stated by NHS EnglandStated in progress
4. Action
  Review mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.
  Stated by NHS EnglandStated in progress
Respondent positions 1
1. Position
  NHS England leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Frazer Charlie Williams · 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

Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his 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
Delays in transferring prisoners requiring mental health hospital admission
Wider context from the report
“i. There is inequity within the system of the treatment of a person with mental illness in the prison setting compared to an individual in the community, due to the fact that in the community a person would be placed in a hospital setting on the day they were deemed to require hospital admission, however in prison there are delays in transferring a prisoner in the same situation to hospital. ”
Source location
Frazer Charlie Williams · Prevention of Future Deaths report
Page 6 · 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
Work with NHS England and His Majesty’s Prison and Probation Service to respond to concerns about delays transferring mentally unwell prisoners to hospital.

Verbatim wording from the response
“I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
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
Review the response to the thematic review and monitor progress in addressing delays transferring mentally unwell prisoners to hospital.

Verbatim wording from the response
“I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce the Mental Health Bill during the current Parliamentary session.

Verbatim wording from the response
“In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The Bill sets out vital reforms to support people with severe mental illness in the criminal justice”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
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
Respond directly to concerns identified in the thematic review of delays transferring mentally unwell prisoners.

Verbatim wording from the response
“I would like to reassure you that NHS England consistently strives for equality in mental health healthcare provision. To address the specific concerns about Frazer’s care, there are several cross party workstreams underway.”

Source location
Response from NHS England
Page 1 · response
Published 6 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Use a clinical template to record and monitor referrals, assessments and transfers under sections 47 and 48 of the Mental Health Act.

Verbatim wording from the response
“A new clinical template for improving data collection and monitoring has been developed and is now in place, to record the referral, assessment and transfer process for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA)”

Source location
Response from NHS England
Page 1 · response
Published 6 June 2024
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
Gather transfer-timeliness data and work with commissioners to improve the quality and completeness of existing data collection.

Verbatim wording from the response
“1983. This template is for use within the health and justice information system (HJIS) in prisons (current SystemOne). NHS England is working to use the information generated to gather data on the timeliness of transfers, whilst also proactively working with Health and Justice commissioners to improve data quality and completeness of existing manual collection.”

Source location
Response from NHS England
Page 2 · response
Published 6 June 2024
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
Review mental health pathway processes, communication and information sharing, then develop a proposed pathway and programme plan addressing identified gaps and priorities.

Verbatim wording from the response
“A review of processes, communication and information sharing around mental health concerns is also underway and will be completed by February 2025. This review is calling “Health and Justice Mental Health Pathway”. Work on the development of a Mental Health Pathway aims to:”

Source location
Response from NHS England
Page 2 · response
Published 6 June 2024
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
NHS England leads the response to delays transferring mentally unwell prisoners to hospital, with the Department reviewing progress.

Verbatim wording from the response
“I share your concerns about the length of time it can take to transfer some mentally unwell prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in NHS England’s response to you, the Department is working with NHS England, and His Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s Inspectorate of Prisons’ thematic review The Long Wait, published in February 2024, which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading on this response, which I will be reviewing and I will be keeping a close eye on how this work progresses.”

Source location
Response from DHSC
Page 1 · response
Published 6 June 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Requirement for pre-planning before secure mental health unit admission

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Lack of psychiatric hospital beds resulting in prolonged emergency department detention

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

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

Concerns raised1

Failure to establish an appropriate admission pathway for worsening patients in the renal unit

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

Concerns raised3

Insufficient availability of ward beds for Emergency Department patient flow

Prolonged waits in Emergency Departments for ward beds

Recurring prolonged waits in Emergency Departments for ward beds

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised2

Delays in emergency treatment caused by unavailable inpatient beds

Failure to free hospital beds occupied by patients medically fit for discharge

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10

Actions described in response 3

Actions described in response 7

Respondent positions 5

Actions described in response 1

Actions described in response 2

Actions described in response 10