Concerns raised 1
Failure to transfer emergency department patients to hospital wards when clinically indicated View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
ROBERT ANDREW PROWSE · 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
Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to transfer emergency department patients to hospital wards when clinically indicated
Wider context from the report “6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge.
7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity.
8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated . This in turn leads to a build up of patients in emergency departments .
” Source location ROBERT ANDREW PROWSE · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the uplift of 5,000 staffed, permanent hospital beds delivered through the urgent and emergency care plan.
Verbatim wording from the response “Your report also highlights that Royal Cornwall Hospital was experiencing high demand with long handover delays. I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals, as you rightly identify in your report, can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022/23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. We have also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 12,000 beds available nationally.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest an additional £1 billion through the Discharge Fund to support timely and effective hospital discharge.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
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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 supporting complex discharges and early planning.
Verbatim wording from the response “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.” Source location Response from Department of Health and Social Care
Open published response
7 Mar 2024 Nicola RAYNER · Prevention of Future Deaths report Suffolk
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Concerns raised 1
Insufficient bed capacity for informal mental health inpatient admissions View source
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AI-generated summary
Nicola RAYNER · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nicola Raynor was found hanging on 6 June 2023 and later died at Addenbrookes Hospital from a hypoxic brain injury. The report raises concerns about the lack of available informal mental health inpatient beds locally and nationally, including continuing insufficient bed capacity for patients awaiting admission.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient bed capacity for informal mental health inpatient admissions
Wider context from the report “Had an informal Mental Health bed been available on the 6th June 2023, and Nicola had been admitted as both she and her psychiatrist had wished, her death would not have occurred.
I am therefore concerned in relation to the overall bed capacity for those patients like Nicola seeking informal inpatient admission.
Nicola’s case is not an isolated one.
Evidence was heard from the Norfolk and Suffolk Foundation Trust, that on the day of the inquest itself (23rd February 2024), the availability of bed provision for informal Mental Health patients had failed to improve at all.
The court heard that on the 23rd February 2024, the Operational Pressure Escalation Level was at its highest level (Four Black) and that at time of Nicola’s inquest, in Suffolk alone, there were 20 patients on a list waiting for an informal inpatient Mental Health bed.
The court heard, that just as on the 6th June 2023, there were no other available informal Mental Health beds anywhere else in the country.
The facts of Nicola’s case mirror those of another tragic Suffolk case, for which I produced a Prevention of Future Death Report in October 2020.
I am therefore concerned, that any measures that may have been taken in the intervening period since October 2020, have neither adequately, or effectively, addressed this clear and continuing local and national risk of future deaths occurring.
” Source location Nicola RAYNER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invest more than £400 million to replace mental health dormitories with ensuite bedrooms, with more than 600 beds already replaced across 34 sites.
Verbatim wording from the response “The strategy is supported by a wide-range of activity the government is funding and that will support people’s mental health. Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7bn (in cash terms). This is significantly above the £3.4bn cash terms growth ambition set out at the time of the Long Term Plan. As part of our plans to improve mental health facilities, we are investing over £400 million to eradicate dormitories and give patients the privacy of their own ensuite bedroom - over 600 beds have already been replaced across 34 sites (out of a total of around 1,400 beds across 50 sites).” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in offloading patients into hospital View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jean Thomas · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in offloading patients into hospital
Wider context from the report “During the course of the inquest it was apparent that the pressure sore was caused by the long lie at home waiting for an ambulance, and then the sore would have been exacerbated by a further long wait in the back of the ambulance waiting to be offloaded into hospital. Issues regarding the treatment of the pressure sore was recognised by the Health Board, consisting of a delay in obtaining an appropriate anti pressure sore mattress and a lack of pressure sore assessment documentation and the issues regarding treatment have been addressed by way of appropriate learning outcomes and action plans.
I am concerned that where vulnerable patients are left waiting for an ambulance then pressure sores can develop due to a long lie. I am further concerned that these sores can be exacerbated in cases where there is a delay in offloading patients into hospital where they can then be nursed on an appropriate anti-pressure sore mattress. Whilst I am aware that the issues raised above occur nationally and are not restricted to the areas that the Welsh Ambulance Service NHS Trust and Swansea Bay University Health Board cover, in my opinion there is a risk that future deaths will occur unless action is taken.
1. There was a significant delay in getting an ambulance to Jean which resulted in a pressure sore forming due to long lie. That pressure sore was exacerbated by a further long wait to be offloaded into hospital . The time taken to offload was in excess of 16 hours, when the target offloading time is 15 minutes ,
” Source location Jean Thomas · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the Welsh Ambulance Service to develop use of pressure-relieving equipment during ambulance transport and delayed handover situations.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply a zero-tolerance threshold to ambulance off-load delays exceeding 10 hours as part of improving handover times.
Verbatim wording from the response “In November 2023, a “zero” tolerance to ambulance off-load delays, in excess of 10 hours, was introduced, at Morriston Hospital. The introduction of this tolerance is part of a reduction trajectory to improving handover times and achieving the 15-minute target. However, despite improvements in this area, continued pressures on the unscheduled care system has resulted in delays over 10 hours still being experienced by patients.” Source location Response from Swansea Bay University Health Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing plans, resource measures and organisational monitoring are considered sufficient, so no further action is proposed on ambulance and hospital delays.
Verbatim wording from the response “Firstly at this time, the Trust does not propose to take any further action or new actions in relation to the matter of ambulance delays in arriving with patients and patients delayed outside of hospitals. The Trust is taking all possible steps within its control to ensure availability of appropriate resources.” Source location Response from Welsh Ambulance Services NHS Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation REACT assessments largely prevent significant harm during delayed ambulance handovers by identifying patient risks and enabling immediate treatment or prevention.
Verbatim wording from the response “The majority of delayed ambulance handover events do not result in a significant harm to a patient. This is largely due to the REACT risk assessment described above. In the rare case when a patient does incur a significant harm, a Duty of Candour process is triggered; notified to the patient and/or family and a full investigation undertaken with the outcome provided in line with “Putting Things Right” (2011) Regulations.” Source location Response from Swansea Bay University Health Board
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use of pressure-relieving ambulance equipment depends on the Welsh Ambulance Service accepting the Health Board’s existing offer of equipment.
Verbatim wording from the response “There is ongoing work in conjunction with the Welsh Ambulance Service to address how pressure relieving equipment can be used on ambulances, both in transit and in situations where patients are unable to be handed over from the ambulance crew to the Emergency Department Team. The Health Board has proactively shared with the Welsh Ambulance Service comprehensive risk assessment documentation relating to the use of pressure relieving mattresses which are able to be used on ambulance trolleys since 2021 (and subsequently in 2023 and 2024). Independent audit outcomes from two Ambulance Trusts in NHS England, who have adopted the use of pressure relieving equipment in ambulance vehicles (using Swansea Bay’s risk assessment) have shown a significant reduction in healthcare acquired pressure injuries of up to 30%.” Source location Response from Swansea Bay University Health Board
Open published response
5 Feb 2024 Abdullah Popalzai · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Unavailability of suitable psychiatric hospital bed spaces in a timely way View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
View source
NHS England
Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
View source
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AI-generated summary
Abdullah Popalzai · 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
Abdullah Popalzai was a remand prisoner at HMP Pentonville who was found hanging in his cell on 29 November 2019, and his death was confirmed by paramedics. He had acute psychosis and required transfer to a psychiatric unit, but no suitable bed was available for a prolonged period. The principal concern was that acutely psychotic prisoners refusing treatment were being left untreated and at risk of deterioration because suitable psychiatric hospital beds were not becoming available in a timely way.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of suitable psychiatric hospital bed spaces in a timely way
Wider context from the report “1) Prisoners who are acutely psychotic and refusing treatment that requires transfer to hospital under the Mental Health Act are being left untreated and at risk of further deterioration due to a shortage of suitable psychiatric hospital bed spaces becoming available in a timely way .
” Source location Abdullah Popalzai · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase timely access to psychiatric hospital beds and provide earlier identification, treatment and support for people in custody who need mental healthcare.
Verbatim wording from the response “NHS England is committed to ensuring access to timely, responsive, and least restrictive mental health care and is already working to address this in this area by focusing on increasing access to hospital beds pre-sentence, rather than prison being used as a place of safety.” Source location Response from NHS England
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address concerns and lessons identified in the HMIP review of delays transferring mentally unwell prisoners.
Verbatim wording from the response “His Majesty’s Inspectorate of Prisons (HMIP) recently published the report The long wait: A thematic review of delays in the transfer of mentally unwell prisoners which outlines similar issues. NHS England is also addressing the areas of concern and lessons learnt within this report.” Source location Response from NHS England
Open published response
Concerns raised 1
Unavailability of hospital beds for informal admission View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Nicolas Gerasimidis · 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
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of hospital beds for informal admission
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available .
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Source location Nicolas Gerasimidis · Prevention of Future Deaths report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Verbatim wording from the response “The ICB are aware of these bed closures and have been assured by CFT that the impact had been mitigated with alternative solutions” Source location Response from DHSC
Open published response
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
Open published response
Concerns raised 1
Failure to admit ambulance patients promptly and return ambulances to active duty View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Betsi Cadwaladr University LHB Welsh Government
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Welsh Government
Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
View source
Welsh Government
Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
View source
Welsh Government
Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.
View source
Welsh Government
Implement an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.
View source
Welsh Government
Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.
View source
Welsh Government
Use monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.
View source
Betsi Cadwaladr University LHB
Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
View source See 4 more actions
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AI-generated summary
Vivienne Greener · 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
Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to admit ambulance patients promptly and return ambulances to active duty
Wider context from the report “9. Ambulances and paramedics are being kept at the Emergency Department as an extension of the hospital and its staff , due to WAST being unable to get their patients admitted into the Emergency Department and back on active duty .
” Source location Vivienne Greener · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate annual priorities requiring health boards to improve ambulance handovers and patient flow.
Verbatim wording from the response “To provide clarity on priorities aligned to A Healthier Wales, I communicate my expectations of health boards and NHS trusts through an annual NHS planning framework. Organisations are expected to produce integrated medium-term plans annually, that respond to the priorities set in the NHS planning framework. The planning framework clearly sets out my expectation that health boards prioritise plans to improve timeliness of ambulance patient handovers to free up ambulance clinicians to respond to patients in the community. Given the relationship between both timely patient discharge and ambulance patient handover, I have also set a priority for improvement in patient flow.” Source location Response from Welsh Government
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a national urgent and emergency care improvement programme and direct health boards to develop local improvement plans.
Verbatim wording from the response “To enable health boards and partners to deliver against these priorities, I established a national urgent and emergency care improvement programme in April 2022 and, in support, have made £50m in additional funding available over the past two years. I directed each health board to develop a local programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. Progress has been made across a number of indicators in recent months to help reduce pressure on emergency care services and to release capacity for patients who need an immediate response:” Source location Response from Welsh Government
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Direct the Chief Ambulance Services Commissioner to monitor improvement plans through Emergency Ambulance Services Committee governance.
Verbatim wording from the response “In addition, I directed the Chief Ambulance Services Commissioner to monitor delivery of plans intended to secure improvements through Emergency Ambulance Services Committee governance mechanisms. The Committee, made up of the seven chief executives of health boards, agreed to work towards eradicating all handover delays over four hours in length by the end of 2024/2025.” Source location Response from Welsh Government
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an NHS Wales ambulance patient handover improvement plan for winter 2023/2024.
Verbatim wording from the response “In view of my concern, all health board chief executives were directed to prioritise three actions for delivery over the winter months as part of a new NHS Wales ambulance patient handover improvement plan implemented from the festive period 2023/2024. As part of their local plan, the Betsi Cadwaladr University Health Board priority actions include:” Source location Response from Welsh Government
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold health board chairs accountable for ambulance handover improvements and seek collective assurance through regular national meetings.
Verbatim wording from the response “• I hold health board chairs to account for delivery and have incorporated ambulance patient handover improvement as a key objective for all chairs for 2023/2024. I consistently seek assurance from chairs as a collective on their organisations’ commitment to making improvements through regular national meetings.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use monthly integrated quality, planning and delivery meetings and six-monthly Joint Executive Team meetings to monitor and challenge ambulance handover performance.
Verbatim wording from the response “• There are established national mechanisms for monitoring the quality, safety and effectiveness of services provided by health boards across Wales. Assurance is sought and challenge provided on a regular basis regarding ambulance patient handover performance, through ‘integrated quality, planning and delivery (IQPD)’ meetings between Welsh Government, the NHS Executive and NHS organisations.” Source location Response from Welsh Government
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scope and formalise additional Emergency Department capacity, including a dedicated speciality waiting area.
Verbatim wording from the response “Processes are taking place in respect of patient flow to release capacity, however, we are reviewing the opportunity to create additional capacity in terms of infrastructure changes and a review of our current START clinical area. This would create a dedicated speciality waiting area with cubicles for review. This scoping is work in progress, and will be formalised.” Source location Response from Betso Cadwaladr University Health Board
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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 delivering health services, including ambulance handover improvements, rests with the health board rather than Welsh Ministers.
Verbatim wording from the response “My response will largely focus upon the ninth matter of concern in the report, regarding the timeliness of ambulance patient handover, and the health board will reply on matters of concerns 1 – 8. My officials have worked with the health board to ensure that our responses are co-ordinated and consistent. It is important to ensure lines of accountability are clear given that responsibility for delivery of services falls with the health board. The role of the Welsh Ministers is to set the strategic direction for health boards and NHS trusts and to hold them to account for delivery of policy.” Source location Response from Welsh Government
Open published response
27 Nov 2023 Luke Mervyn WHITELAW · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to re-admit patients to hospital when indicated View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Luke Mervyn WHITELAW · 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
Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to re-admit patients to hospital when indicated
Wider context from the report “(1) Mr Lockwood’s re-admission to hospital was indicated as early as 2 February 2023; however, he was not re-admitted to hospital, informally or otherwise.
” Source location Luke Mervyn WHITELAW · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the acute mental health patient-flow and bed-management policy to guide inpatient admission decisions.
Verbatim wording from the response “Oxleas Acute Mental Health Patient Flow and Bed Management policy (updated in December 2023) provides guidance on the purpose of an inpatient admission; and actions to be taken when Crisis Resolution and Home Treatment Team (CRHTT) identify that someone’s clinical needs indicate that” Source location Response from Oxleas NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train clinicians to document medication and medical-review discussions, decisions, participants, timings and outcomes.
Verbatim wording from the response “We have discussed with the team members of CRHTT the need to precisely document discussions about medication or medical review in future (i.e. to outline date and time of discussion, who was involved in the discussion, and the outcome that was agreed). Since this time, significant discussion and training has taken place with all clinicians in this team to document key discussions and decisions – including when the clinical needs changes to the point that inpatient care is indicated. Training and discussion has also taken place during 2023 and into 2024 with the consultant psychiatrists, managers and clinical staff about meaningful discussion and documentation of same, and consideration of written notes.” Source location Response from Oxleas NHS Foundation Trust
Open published response
29 Sep 2023 John Trevor WINSWORTH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Delays in admission to Accident and Emergency Department View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Department of Health and Social Care
Publish the delivery plan for recovering urgent and emergency care services.
View source
Department of Health and Social Care
Deliver 5,000 more staffed, permanent hospital beds than planned for 2022/23.
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Department of Health and Social Care
Maintain the increased staffed, permanent hospital bed capacity in 2024/25.
View source
Department of Health and Social Care
Scale up virtual ward capacity beyond 10,000 beds, with over 11,000 beds available nationally.
View source
Department of Health and Social Care
Provide £1.6 billion over two years to support timely and effective hospital discharge.
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AI-generated summary
John Trevor WINSWORTH · 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 Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to calls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in admission to Accident and Emergency Department
Wider context from the report “2. The ambulance arrived at the Norfolk and Norwich University Hospital at 10.52 hours and Mr Winsworth was not able to be admitted to Accident and Emergency Department until 14.42 hours; over 3 hours following admission, due to pressure on the hospital.
” Source location John Trevor WINSWORTH · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the delivery plan for recovering urgent and emergency care services.
Verbatim wording from the response “As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes across this fiscal year. The plan is available at https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf.” Source location Response from Department of Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 more staffed, permanent hospital beds than planned for 2022/23.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the increased staffed, permanent hospital bed capacity in 2024/25.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scale up virtual ward capacity beyond 10,000 beds, with over 11,000 beds available nationally.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide £1.6 billion over two years to support timely and effective hospital discharge.
Verbatim wording from the response “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We also have provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.” Source location Response from Department of Health and Social Care
Open published response
Concerns raised 1
Delays in ambulance handover at hospitals View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Jean Frickel · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in ambulance handover at hospitals
Wider context from the report “There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available.
I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies.
I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals ).
I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future.
Specifically, I require responses to the following:-
1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and
2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and
3. Extent of Strategic plan of action / improvement plan to address the above issues.
” Source location Jean Frickel · Prevention of Future Deaths report
Open source report
4 Feb 2023 Benjamin Paul Stanley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Insufficient hospital bed capacity View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Benjamin Paul Stanley · 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
Benjamin Paul Stanley developed chronic pancreatitis, became severely malnourished, and was admitted to Stepping Hill Hospital on 11 May 2022. He deteriorated, developing liver cirrhosis, sepsis and a Clostridium difficile infection, and died in hospital on 19 May 2022. The concerns identified included prolonged waits in A&E linked to demand and a lack of beds; in his case, direct entry to a ward was considered to have been in his best interests, but he had to wait in A&E for a bed.
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 hospital bed capacity
Wider context from the report “The Inquest heard evidence of significant waits in Accident and Emergency (A&E) to be seen due to the pressure on the department. The Inquest heard that the hospital had not improved since his death and there were regular waits in excess of 11 hours in A&E due to demand on services which impacted on patients care and treatment. The position was not unique to the particular Trust but was replicated in Trusts across Greater Manchester.
The Inquest was told that prolonged waits in A&E were also due to a lack of beds with the hospital . In Mr Stanley’s case direct entry to a ward would have been in his best interests. However lack of capacity meant that he had to be advised to go to A&E and wait for a bed .
” Source location Benjamin Paul Stanley · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver 5,000 additional staffed, permanent hospital beds to increase capacity and improve patient flow.
Verbatim wording from the response “A key part of the plan has been to increase hospital capacity to improve patient flow and reduce overcrowding in A&E. We have achieved the ambition of delivering 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make £1.6 billion available over two years to support timely hospital discharge and free beds.
Verbatim wording from the response “We recognise that a whole-system approach is needed to ensure people get the emergency care they need when they need it. This is why we have made £1.6 billion of funding available over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital, helping to free up beds and reduce long waits for admission from A&E. NHS England also launched its universal support offer, available to all systems, including Stockport NHS Foundation Trust which supported systems to implement high impact initiatives and improve emergency care performance ahead of winter this year.” Source location Response from Department of Health and Social Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.