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.

26 Jun2018
North Wales (East and Central)
Concerns raised1
1. Failures in admission to the emergency department
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Margaret Megan Evans · 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

Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.

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
Failures in admission to the emergency department
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on numerous occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result. ”
Source location
Margaret Megan Evans · Prevention of Future Deaths report
Page 1 · concerns
Open source report
6 Jun2018
North Wales (East and Central)
Concerns raised1
1. Failure to ensure timely admission to the emergency department
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ester Jane Wood · 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

Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.

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 ensure timely admission to the emergency department
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions following previous inquests, most recently on 17th May 2017 by Mr Gittins, Senior Coroner concerning the death of Lilly Baxendall. Despite the above reports issued to the Health Board and other relevant bodies these problems continue to the present day and patients' lives are being placed at risk as a result. ”
Source location
Ester Jane Wood · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Jul2017
North Wales (East and Central)
Concerns raised1
1. Failure to ensure effective admission to the Emergency Department
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Catherine Haf Roberts · 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

Catherine Haf Roberts arrived at hospital by ambulance after becoming unwell with persistent diarrhoea and waited outside before remaining in the emergency department for 58 hours because of capacity and ward-space constraints. Her condition deteriorated after transfer to a medical ward, and she died in hospital on 11 February 2016. The principal concern was the continuing lack of an agreed and effective system plan addressing emergency department admission, resource availability and patient flow, which the report states was placing patients’ lives at risk.

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 ensure effective admission to the Emergency Department
Wider context from the report
“The issues of admission to the Emergency Department/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by the Senior Coroner on several occasions following previous inquests. Despite the above reports issued to the Health Board these problems continue to the present day and patients lives are being placed at risk as a result. Whilst I am aware that all necessary parties are working towards a system plan to address these issues and that elements of that plan have been agreed, there remains no agreed and effective system plan in place. ”
Source location
Catherine Haf Roberts · Prevention of Future Deaths report
Page 1 · concerns
Open source report
25 May2017
North Wales (East and Central)
Concerns raised1
1. Continuing problems with admission to the emergency department
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 8
1. Action
  Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
3. Action
  Recruit additional ED nursing and medical staff and increase the funded staffing establishments.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
1. Action
  Align senior medical staffing hours with peak ED demand, including extended consultant cover.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
2. Action
  Increase specialty medical and surgical in-reach to assess ED patients before inpatient admission.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
3. Action
  Review and amend medical and nursing rotas to reflect ED demand and increase senior cover.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completed
4. Action
  Introduce unified assessment documentation for patients awaiting admission from ED.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progress
5. Action
  Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit ED and GP patients promptly.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated planned
Respondent positions 1
1. Position
  Establishing a North Wales Bed Bureau was not considered feasible for improving acute hospital access because of geography and local-admission priorities.
  Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustUnable to act
AI-generated summary

Daphne Edith 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

Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her 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
Continuing problems with admission to the emergency department
Wider context from the report
“The issues of ambulance delays/admission to ED/availability of resources/patient flow and the multifactorial problems associated with cases of this nature have been reported upon by me on several occasions following previous inquests. Despite the above reports issued to the Health Board and Ambulance Service these problems continue to the present day and patients’ lives are being placed at risk as a result. ”
Source location
Daphne Edith Williams · 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
Explore establishing a Rapid Assessment and Treatment area at Ysbyty Glan Clwyd.

Verbatim wording from the response
“At Ysbyty Maelor Wrecsam, a holding area in ED is created whenever possible during the day to enable patients of low risk to be handed over without delay by WAST and brought into ED. At Ysbyty Glan Clwyd, options are being explored to establish a physical ‘RATS’ (Rapid Assessment & Treatment Service) area in ED to enable the rapid handover and assessment of patients.”

Source location
2017-0167-Response-by-University-Health-Board
Page 6 · response
Published 31 August 2017
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
Expand Ysbyty Glan Clwyd ED capacity through additional assessment spaces, observation beds, and flexible use of available clinical areas.

Verbatim wording from the response
“• A review of the use of the physical space within ED has created an open ambulatory chair centric area with 4 additional assessment/treatment spaces; the commissioning of 2 additional beds in the observation bedded area of the ED; the use of the co-located GP Out of Hours area during the day (Monday to Friday, 9am - 5pm) to provide 4 rooms for assessment / treatment; and the adoption of a flexible approach, in extenuating circumstances, to the use of all space within the ED during times of peak pressure.”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
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
Recruit additional ED nursing and medical staff and increase the funded staffing establishments.

Verbatim wording from the response
“• On-going recruitment of nursing and medical staff is a key focus. This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staff to all posts although recent recruitment campaigns for senior medical staff have met with success. It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible.”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
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
Align senior medical staffing hours with peak ED demand, including extended consultant cover.

Verbatim wording from the response
“• The service is also working towards better matching senior medical staff working hours with times of peak patient demand. The aim is to have the Consultant late day shift extended from 18.00hrs to 22.00hrs and have a second Consultant working until 9pm Monday to Friday”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
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 specialty medical and surgical in-reach to assess ED patients before inpatient admission.

Verbatim wording from the response
“• Work is also on-going to increase specialty ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.”

Source location
2017-0167-Response-by-University-Health-Board
Page 7 · response
Published 31 August 2017
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 and amend medical and nursing rotas to reflect ED demand and increase senior cover.

Verbatim wording from the response
“• Medical and nursing staffing rotas have been reviewed and amended to better reflect the peaks of patient demand in ED and changes have also been made to increase the senior level cover in the department.”

Source location
2017-0167-Response-by-University-Health-Board
Page 8 · response
Published 31 August 2017
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 unified assessment documentation for patients awaiting admission from ED.

Verbatim wording from the response
“• A modified form of unified assessment documentation for patients awaiting admission from ED has been under development. This supports the provision of inpatient level type care to ED patients, ensuring their clinical outcomes and treatment is not compromised. It is intended to fully introduce this process in early August, following a period of trial to ensure all documentation and processes are fully fit for purpose.”

Source location
2017-0167-Response-by-University-Health-Board
Page 8 · response
Published 31 August 2017
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
Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit ED and GP patients promptly.

Verbatim wording from the response
“• From the 1st August 2017, a rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with a Frailty Assessment Unit with a focus on admission avoidance to return individuals to their own homes with the support of community staff, including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours. Patients will be treated as ambulatory until proven otherwise and within the unit, individuals will receive rapid diagnosis and stabilisation before they are supported home.”

Source location
2017-0167-Response-by-University-Health-Board
Page 9 · response
Published 31 August 2017
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
Establishing a North Wales Bed Bureau was not considered feasible for improving acute hospital access because of geography and local-admission priorities.

Verbatim wording from the response
“In reviewing the action plans already submitted in response to previous Regulation 28 reports relating to patient flow, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling the admission of emergency patients to as local a hospital as possible, as often as possible.”

Source location
2017-0167-Response-by-University-Health-Board
Page 1 · response
Published 31 August 2017
Open published response
17 May2017
North Wales (East and Central)
Concerns raised2
1. Insufficient hospital bed capacity for admissions
2. Failure of hospital patient flow and delayed transfer of care processes
This report raised 2 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
  Open additional surge inpatient capacity during peak demand where staffing permits safe operation.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
2. Action
  Create a Step Down Manager post to coordinate movement of complex-care patients through discharge pathways.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
3. Action
  Implement the SAFER patient-flow bundle across all three acute hospital sites.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
1. Action
  Provide dedicated hospital social-work staffing and rapid reablement support for discharge in Flintshire.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
2. Action
  Invest in integrated generic health and social-care support staff to assist hospital discharges in Wrexham.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
3. Action
  Establish five short-term extra-care apartments to support admission avoidance and timely discharge in Conwy.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
4. Action
  Establish a joint Single Point of Access and step-down cluster to support hospital discharge in Denbighshire.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
5. Action
  Develop enhanced multidisciplinary community resource teams to provide care at home.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
6. Action
  Increase specialty medical and surgical in-reach into ED to support earlier assessment and discharge.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
7. Action
  Create a Night Sister post to support patient flow and safety at Ysbyty Maelor Wrexham.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
8. Action
  Trial Frailty Assessment Units to support front-door assessment and admission avoidance.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated planned
9. Action
  Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit patients from ED and primary care without undue delay.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
10. Action
  Provide overnight district nursing in Wrexham to support safe care at home.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated completed
11. Action
  Develop the IV suite to provide emergency and elective IV therapy without overnight admission.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
12. Action
  Develop patient-transfer, discharge, routine and repatriation guidance for ambulance-resource requests.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
Respondent positions 1
1. Position
  Establishing a North Wales Bed Bureau was not feasible because geography and local emergency admissions require access to the nearest appropriate hospital.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilUnable to act
AI-generated summary

Lilly Baxandall · 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

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

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 for admissions
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Source location
Lilly Baxandall · 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
Failure of hospital patient flow and delayed transfer of care processes
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Source location
Lilly Baxandall · 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
Open additional surge inpatient capacity during peak demand where staffing permits safe operation.

Verbatim wording from the response
“• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the use of medical and surgical assessment spaces as overnight inpatient beds and the escalation of additional beds on some wards where staffing levels enable this to be done safely.”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
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
Create a Step Down Manager post to coordinate movement of complex-care patients through discharge pathways.

Verbatim wording from the response
“• A ‘Step Down’ Manager post has been created who works collaboratively with community health and social care colleagues to ensure that patients with complex care needs are moved to the next stage of their care pathway without undue delay”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
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 SAFER patient-flow bundle across all three acute hospital sites.

Verbatim wording from the response
“4.3. SAFER BCUHB has committed to implement the SAFER bundle in all 3 acute hospital sites over the next 6 months. This is an evidence based bundle of actions shown to reduce length of stay and support safe patient discharge. The key elements of this are:”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
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 dedicated hospital social-work staffing and rapid reablement support for discharge in Flintshire.

Verbatim wording from the response
“Flintshire has community based, responsive Community Care services which work effectively to prevent people being admitted to hospital when it is feasible and safe for these people to be supported at home. We have a leading Reablement Service which intervenes effectively, often on the same day and certainly with due urgency to ensure people maintain their independence, do not deteriorate and are supported at home. We also have a fully functioning Single Point of Access with involvement of the Voluntary Sector and co-located with Health. Finally, Flintshire leads on behalf of Wrexham, BCUHB and our County with a Community Equipment Service which provides rapid and responsive equipment again if needed, on the same day. There are 10 dedicated hospital social workers to facilitate discharge as soon as an individual is medically fit to leave the acute hospital.”

Source location
2017-0160-Response-by-University-Health-Board
Page 11 · response
Published 17 August 2017
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
Invest in integrated generic health and social-care support staff to assist hospital discharges in Wrexham.

Verbatim wording from the response
“Provision of dedicated hospital social workers and Assistant Team Manager to facilitate discharge as soon as an individual is medically fit to leave the acute hospital. The social workers are based at the Maelor Hospital and Chirk community hospital and are integrated with the Discharge Liaison team.”

Source location
2017-0160-Response-by-University-Health-Board
Page 12 · response
Published 17 August 2017
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
Establish five short-term extra-care apartments to support admission avoidance and timely discharge in Conwy.

Verbatim wording from the response
“Conwy have established 5 successful short term apartments at our Extra Care Housing Schemes. These apartments provide individuals with their own flat and an on-site support teams focused on Reablement and retaining independence. This supports individuals to either avoid a hospital admission or facilitate discharge to an intermediate facility before (primarily) returning home. These beds have further strengthened our ability to offer appropriate and timely discharge for people who are medically fit to leave inpatient beds but are not yet ready to go home.”

Source location
2017-0160-Response-by-University-Health-Board
Page 13 · response
Published 17 August 2017
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
Establish a joint Single Point of Access and step-down cluster to support hospital discharge in Denbighshire.

Verbatim wording from the response
“This has resulted in a number of changes to how services have been provided in the past and include a joint Single Point of Access with agreed pathways for discharge from hospital and a co-located Community Team of health and social care professionals able to work together more effectively. The latter will be rolled out across the County when its effectiveness has been reviewed.”

Source location
2017-0160-Response-by-University-Health-Board
Page 14 · response
Published 17 August 2017
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 enhanced multidisciplinary community resource teams to provide care at home.

Verbatim wording from the response
“• Developing enhanced multi-disciplinary community resource teams (CRT) to provide more care for individuals in their own homes. The CRTs are in varying degrees of development across North Wales and whilst have the potential to better manage care closer at home need to build on the range of successful intermediate care provision already delivered in the 6 local authorities.”

Source location
2017-0160-Response-by-University-Health-Board
Page 5 · response
Published 17 August 2017
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 specialty medical and surgical in-reach into ED to support earlier assessment and discharge.

Verbatim wording from the response
“• Work is also on-going to increase speciality ‘in reach’ into ED by medical and surgical specialties who attend ED to review patients rather than wait for them to be admitted to an inpatient ward. This does result in some patients being discharged home from ED.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
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
Create a Night Sister post to support patient flow and safety at Ysbyty Maelor Wrexham.

Verbatim wording from the response
“• A Night Sister post has been put in place to assist the Clinical Site Manager with patient flow and associated quality and safety issues”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
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
Trial Frailty Assessment Units to support front-door assessment and admission avoidance.

Verbatim wording from the response
“• In early autumn, a Frailty Assessment Unit will be trialled, providing a more comprehensive assessment of frail patients at the ‘front door’ with the aim of avoiding admission for some of these by providing additional community support to enable patients to be safely managed in their own homes. This needs further discussion with the local authorities.”

Source location
2017-0160-Response-by-University-Health-Board
Page 8 · response
Published 17 August 2017
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
Operate a rapid assessment unit at Ysbyty Maelor Wrexham to assess and admit patients from ED and primary care without undue delay.

Verbatim wording from the response
“• From the 1st August 2017, a rapid assessment unit will be operational to assess and admit patients from ED (and GPs) without undue delay. From the autumn, this will be complimented with a Frailty Assessment Unit with a focus on admission avoidance to return individuals to their own homes with the support of community staff, including therapists. The unit will provide rapid assessment and treatment of patients who have the potential to return home the same day or within a maximum of 72 hours. Patients will be treated as ambulatory until proven otherwise and within the unit, individuals will receive rapid diagnosis and stabilisation before they are supported home.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
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 overnight district nursing in Wrexham to support safe care at home.

Verbatim wording from the response
“• During times of peak demand, additional ‘surge’ inpatient bed capacity is opened in line with available staffing. This includes the escalation of additional beds on some wards where staffing levels enable this to be done safely. The District Nursing Service in Wrexham is now available overnight, enabling more patients to be safely cared for at home rather than remain in hospital.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
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 the IV suite to provide emergency and elective IV therapy without overnight admission.

Verbatim wording from the response
“• The provision of an IV suite continues to develop as an important service to enable individuals to receive IV therapy as a day attender (both emergency and elective) without the need for an overnight hospital stay.”

Source location
2017-0160-Response-by-University-Health-Board
Page 9 · response
Published 17 August 2017
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 patient-transfer, discharge, routine and repatriation guidance for ambulance-resource requests.

Verbatim wording from the response
“Healthcare Inspectorate Wales is soon due to commence a patient discharge thematic review within BCUHB which may identify new actions for the Health Board and possibly its partners to complete to realise improvements to the discharge planning process. WAST is currently developing ‘Patient Transfer, Discharge, Routine and Repatriation Guidance’ to ensure that WAST and the wider NHS community fully understand the process of requesting an ambulance resource for particular groups of patients who need transport to enable their discharge/transfer to another facility. This will help ensure timely discharge using the most appropriate resource whilst also maintaining the availability of WAST resources to respond to 999 calls.”

Source location
2017-0160-Response-by-University-Health-Board
Page 10 · response
Published 17 August 2017
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
Establishing a North Wales Bed Bureau was not feasible because geography and local emergency admissions require access to the nearest appropriate hospital.

Verbatim wording from the response
“In reviewing the action plans already submitted in response to the 7 previous Regulation 28 reports that are referenced in the Regulation 28 for Lilly Baxandall, BCUHB notes that all previous actions have been implemented or are work in progress, with the exception of the establishment of a North Wales Bed Bureau. After consideration of this, it was not deemed a feasible way of improving access for acute hospital admissions across North Wales due to geography and enabling the admission of emergency patients to as local a hospital as possible, as often as possible.”

Source location
2017-0160-Response-by-University-Health-Board
Page 1 · response
Published 17 August 2017
Open published response
5 Apr2017
Brighton and Hove
Concerns raised1
1. Lack of hospital bed availability delaying patient admission
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 5
1. Action
  Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
2. Action
  Review service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
3. Action
  Implement the SAFER care bundle to improve patient flow and support earlier discharge.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
1. Action
  Expand Newhaven Downs Community Hospital to create additional discharge capacity.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
2. Action
  Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.
  Stated by University Hospitals Sussex NHS Foundation TrustStatus unclear
Respondent positions 1
1. Position
  Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.
  Stated by South East Coast Ambulance Service NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Ronald William Bennett · 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

Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute 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
Lack of hospital bed availability delaying patient admission
Wider context from the report
“(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day). (2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate. (3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds. (4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death. (5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH. ”
Source location
Ronald William Bennett · 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
Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.

Verbatim wording from the response
“(3) We now have a £31m capital scheme in development to expand the emergency floor, including an expanded Urgent Care Centre at the Royal Sussex County Hospital, more GP input to the Emergency Department and an ambulatory emergency care facility in advance of next winter.”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
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 service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
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 SAFER care bundle to improve patient flow and support earlier discharge.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
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
Expand Newhaven Downs Community Hospital to create additional discharge capacity.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
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
Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.

Verbatim wording from the response
“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location
2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017
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
Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.

Verbatim wording from the response
“Although I cannot give you assurance that this complex and multi-factorial problem is fixed, I am confident that the matter is now being given sufficient priority by our acute, community and primary care partners. Its impact on our services is significant, and we are doing all we reasonably can to ensure improvement is sustained.”

Source location
2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 28 July 2017
Open published response
14 Mar2017
North Wales (East and Central)
Concerns raised2
1. Patient flow failing to enable admission of patients requiring treatment
2. Delays in admission to hospital
This report raised 2 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
  Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Use predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Increase emergency-department capacity by opening additional minor-attendance rooms and converting trolley space into a four-chair ambulatory area.
  Stated by Betsi Cadwaladr University LHBStated completed
1. Action
  Strengthen out-of-hours site management through twilight managers, a new clinical rota, additional night sisters and a senior manager role.
  Stated by Betsi Cadwaladr University LHBStated in progress
2. Action
  Develop a revised Bronze and Silver on-call model with dedicated 24-hour Silver cover, clinical support and strengthened site-management resilience.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Develop surge-capacity arrangements for peak evening and overnight demand using previously unstaffed clinical space.
  Stated by Betsi Cadwaladr University LHBStated completed
4. Action
  Use medical-fit-for-discharge data to develop escalation pathways and teams, including the YGC Step Down Team, for alternative discharge or transfer options.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Rebecca Anne Evans · 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

Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and ambulance availability.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Patient flow failing to enable admission of patients requiring treatment
Wider context from the report
“3. It is of grave concern to me that my statutory duty requires me to report these concerns by way of regulation 28 reports on a very regular basis and that despite previous such reports there continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment. ”
Source location
Rebecca Anne Evans · 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
Delays in admission to hospital
Wider context from the report
“1. That there were significant delays in the admission of Ms Evans to Hospital and that medical treatment was consequently not commenced in a timely manner. ”
Source location
Rebecca Anne Evans · 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
Develop and implement the Unscheduled Care Plan, supported by metrics for emergency access and ambulance handover improvement.

Verbatim wording from the response
“Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached. The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target.”

Source location
2017-0077-Response-by-University-Health-Board
Page 1 · response
Published 24 March 2017
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 predictive demand, capacity, flow and performance information routinely to guide unscheduled-care resourcing and operational decisions.

Verbatim wording from the response
“The use of information within Unscheduled Care decision making There is extensive use of predictive tools and modeling within our overall approach to Unscheduled Care. The overall capacity and demand model developed by the planning section has informed the scale of improvement required to achieve a bed occupancy level of 85%. The metrics within the overall plan are calibrated at a level which has been calculated to enable the 4 hour target to be achieved and improve ambulance handover.”

Source location
2017-0077-Response-by-University-Health-Board
Page 2 · response
Published 24 March 2017
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 emergency-department capacity by opening additional minor-attendance rooms and converting trolley space into a four-chair ambulatory area.

Verbatim wording from the response
“6. Emergency department Capacity; both EDs have reviewed the demand profiles and commissioned additional clinical capacity. WMH have opened two additional examination rooms for minor attendances to protect the minors stream. YGC have converted one minors trolley space to a four chair ambulatory area to increase minors stream capacity.”

Source location
2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017
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 out-of-hours site management through twilight managers, a new clinical rota, additional night sisters and a senior manager role.

Verbatim wording from the response
“7. Operational site management; WMH have employed twilight site managers to support evening bed pressures. All three acute hospitals in the Health Board are moving towards a new out of hours site management clinical rota to support flow and response to escalation. This includes additional night sisters to support core site management. WMH also provide a Senior Manager of the day who works till 8pm to support decompression of acute problems affecting flow.”

Source location
2017-0077-Response-by-University-Health-Board
Page 3 · response
Published 24 March 2017
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 revised Bronze and Silver on-call model with dedicated 24-hour Silver cover, clinical support and strengthened site-management resilience.

Verbatim wording from the response
“10. Senior Manager Bronze and Silver on call arrangements; a formal review of Bronze and Silver on call manager rotas in recognition of the demands of unscheduled care pressures has informed the development of a new model. This includes”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
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 surge-capacity arrangements for peak evening and overnight demand using previously unstaffed clinical space.

Verbatim wording from the response
“11. Evening / Overnight Capacity; all sites have developed surge capacity options to meet periods of peak demand during the evening and overnight. This utilizes physical capacity that would not normally be staffed overnight, therefore increasing capacity and utilization of core clinical estate.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
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 medical-fit-for-discharge data to develop escalation pathways and teams, including the YGC Step Down Team, for alternative discharge or transfer options.

Verbatim wording from the response
“12. Development of Medical Fit to Discharge data; WMH and YGC have used data extracted specifically from WPAS and local data collection to identify patients fit for discharge but delayed due to factors outside of the acute hospital control. This has resulted in the development of new escalation pathways and teams, such as the Step Down Team at YGC to secure alternative discharge / transfers options for MFDs contributing to bed blockages and bed turn over.”

Source location
2017-0077-Response-by-University-Health-Board
Page 4 · response
Published 24 March 2017
Open published response
13 Jan2017
North Wales (East and Central)
Concerns raised1
1. Insufficient hospital bed capacity causing delays in admissions
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 3
1. Action
  Provide joint community and hospital services to avoid admissions where patients can safely be cared for at home.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Implement the Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.
  Stated by Betsi Cadwaladr University LHBStated planned
3. Action
  Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.
  Stated by Betsi Cadwaladr University LHBStated completed
AI-generated summary

Sarah Ann Tyler · 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

Sarah Ann Tyler was admitted to the Emergency Department on 8 February 2015 following an overdose of co-codamol and, while awaiting admission, used ECG leads as a ligature, resulting in a hypoxic brain injury. The substantive concerns were delays in hospital admissions due to insufficient beds and more acute bed blocking at weekends because of reduced discharges.

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 causing delays in admissions
Wider context from the report
“1. That there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions. 2. That the issue of “bed blocking” is more acute at weekends due to reduced numbers of patients being discharged from hospital. ”
Source location
Sarah Ann Tyler · 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
Provide joint community and hospital services to avoid admissions where patients can safely be cared for at home.

Verbatim wording from the response
“Admission Avoidance Patients attend ED as a method of gaining access to health services. The Unscheduled Care plan sets out the overall approach to ensuring that wherever possible, patients can be treated without requiring admission to a hospital bed. The plan describes how community services and hospital services will be provided jointly so that patients will be provided with the same community services, irrespective of whether they present to our services through the GP or via the Emergency Department. For example, if a patient who is already known to community services attends ED, the District Nursing team are automatically informed and will attend to review if the patient can be cared for at home.”

Source location
2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017
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 Unscheduled Care Plan to reduce admissions, shorten hospital stays and improve timely access to inpatient beds.

Verbatim wording from the response
“Whilst the majority of patients are treated or admitted within the acceptable time, a significant minority took longer to be treated or admitted and a proportion of these will have waited significantly longer. The Health Board is required by Welsh Government to have a plan in place so that performance against the 4 hour target is improved, and that more patients are treated or admitted within 4 hours. The plan to achieve this improvement is set out in the Health Board’s plan for Unscheduled Care Plan, which is a chapter within the overall Health Board Operational Plan for 2017/8. The Unscheduled Care Plan is attached in appendix 1. (The plan is a draft at this stage pending feedback on the draft from Welsh Government).”

Source location
2017-0002-Response-by-University-Health-Board
Page 1 · response
Published 19 February 2017
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
Complete joint assessment of delayed-transfer and length-of-stay causes with local authorities and independent care providers.

Verbatim wording from the response
“Reducing Length of Stay In addition to the work to reduce admissions, there is also a significant focus on reducing the time spent in hospital for patients that are admitted. Patients who experience a Delayed Transfer of Care (DTOC) wait for transfer to be arranged to a care home or for a support package to be provided in their own home. The Health Board carried out a detailed joint assessment of the issues that cause delay in December 2016 jointly with Local Authorities and the Independent Sector providers of care services (care home and home care). The plans to reduce DTOCs and length of stay are set out in the plan.”

Source location
2017-0002-Response-by-University-Health-Board
Page 2 · response
Published 19 February 2017
Open published response
4 Sep2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs. Mary Patricia James · 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

Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

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 admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report
“(4) That against this background and the Care Home’s concern about a possible ischaemic leg, Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy. ”
Source location
Mrs. Mary Patricia James · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Apr2015
Wiltshire and Swindon
Concerns raised1
1. Unavailability of hospital beds for patients requiring admission at Green Lane Hospital Devizes
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
  Monitor bed pressures and out-of-area placements.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated completed
2. Action
  Work with commissioners and NHS England to manage bed pressures and out-of-area placements.
  Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated in progress
AI-generated summary

Andrew Ralph Mitchell Farrow · Prevention of Future Deaths report

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

Report summary

Andrew Ralph Mitchell Farrow died at home on 7 July 2014 as a result of self-administered acute codeine and alcohol toxicity. He had expressed a wish to be admitted to hospital for his own safety, and the concern was that no beds would have been available at Green Lane Hospital Devizes if admission had been needed.

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 hospital beds for patients requiring admission at Green Lane Hospital Devizes
Wider context from the report
“He was known to have suicidal ideation but no actual plan had been formulated. I did not find that he ought to have been admitted. My concern however is that had he needed admitting it is apparent no beds would have been available at Green Lane Hospital Devizes when an enquiry was made on 6 July 2014 by North Wiltshire Intensive Services. ”
Source location
Andrew Ralph Mitchell Farrow · 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
Monitor bed pressures and out-of-area placements.

Verbatim wording from the response
“When there is a bed pressure in a locality, clinical staff may take a number of different actions, depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking an bed in another part of the Trust, making a bed available by seeing if there are patients who need to be discharged, or sending a patient out of the Trust’s area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family. When a patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

Source location
2015-0147-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 20 April 2015
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with commissioners and NHS England to manage bed pressures and out-of-area placements.

Verbatim wording from the response
“When there is a bed pressure in a locality, clinical staff may take a number of different actions, depending upon the requirements of the individual patient. These actions may include seeking alternatives to admission such as intensive home treatment, seeking an bed in another part of the Trust, making a bed available by seeing if there are patients who need to be discharged, or sending a patient out of the Trust’s area. The decision is always risk based, and takes account as far as is possible the wishes of the patient and their family. When a patient is sent out of area, every effort is made to repatriate them locally as soon as it is possible and in their best interests to do so. The Trust Board closely monitors bed pressures and out of area placements and is continually working with its Commissioners and NHS England to manage the situation optimally.”

Source location
2015-0147-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 20 April 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failures in admission to the emergency department

Concerns raised1

Failure to ensure timely admission to the emergency department

Concerns raised1

Failure to ensure effective admission to the Emergency Department

Concerns raised1

Continuing problems with admission to the emergency department

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.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Insufficient hospital bed capacity for admissions

Failure of hospital patient flow and delayed transfer of care processes

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.15

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 8

Respondent positions 1

Actions described in response 15

Respondent positions 1