Recurring concern

Failure to ensure timely transfer to an appropriate hospital care environment

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First reported 23 Sep 2013•Latest report 24 Jun 2026

Definition

What this concern includes

Includes failures of the hospital transfer, bed-allocation or placement process that delay or prevent timely movement from an inappropriate setting to an available and clinically appropriate ward or alternative care environment.

Not included

Excludes failures concerning only the quality or suitability of a care environment when no delayed or inappropriate transfer or placement process is identified.
Excludes generic staffing, resource or bed-capacity deficiencies unless they are directly tied to delayed or failed transfer or placement in an appropriate care environment.
Excludes unrelated admission, discharge, clinical-treatment or risk-assessment failures that do not concern transfer or placement in the appropriate hospital setting.

Reports: 24
Individual concerns: 24
Date range: 2013–2026
Stated actions: 67

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 Care10

NHS England4

Greater Manchester Health and Social Care Partnership3

Betsi Cadwaladr University LHB2

Care Quality Commission2

University Hospitals Sussex NHS Foundation Trust2

Welsh Ambulance Services NHS Trust2

Aneurin Bevan University LHB1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Chief Executive of National Institution for Health and Care Excellence1

Chief Executive of Royal College of Midwives1

Chief Executive of Royal College of Obstetricians and Gynaecologists1

Consultant orthopaedic surgeon1

Conwy County Borough Council1

Denbighshire County Council1

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.

20 Apr2023
Suffolk
Concerns raised1
1. Failure to promptly transfer patients to an available ward bed or appropriate alternative place
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 2
1. Action
  Publish a national delivery plan setting out steps to recover urgent and emergency care services, including expanded community services for older people with frailty.
  Stated by NHS EnglandStated completed
2. Action
  Work with Integrated Care Systems to provide streamlined pathways for older adults, including people with dementia.
  Stated by NHS EnglandStated planned
AI-generated summary

Joseph Willy Maunick · 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

Joseph Willy Maunick died on 15 March 2022 from a severe head injury sustained in a fall in the Emergency Department of West Suffolk Hospital, where he had been admitted as a social admission while his wife underwent emergency surgery. The report identified concerns about a national shortage of suitable care, and severe hospital pressures including insufficient staffing and resources, which prevented the constant supervision he needed and delayed transfer to a more appropriate environment.

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 promptly transfer patients to an available ward bed or appropriate alternative place
Wider context from the report
“2) The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future. ”
Source location
Joseph Willy Maunick · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish a national delivery plan setting out steps to recover urgent and emergency care services, including expanded community services for older people with frailty.

Verbatim wording from the response
“In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.”

Source location
Response from NHS England
Page 2 · response
Published 27 April 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with Integrated Care Systems to provide streamlined pathways for older adults, including people with dementia.

Verbatim wording from the response
“In January 2023, the Delivery plan for recovering urgent and emergency care services was published by NHS England, which sets out the steps that the NHS are taking to respond to the demand being placed on urgent and emergency care (UEC) services at a national level. The plan also includes details for the expansion of community services including more joined-up care for older people living with frailty, including scaling up urgent community response, frailty and falls services across the whole country – meaning the right people delivering the right care and avoiding admission to hospital where it’s not necessary. We will also work with Integrated Care Systems (ICSs) to provide streamlined pathways for older adults, including people with dementia.”

Source location
Response from NHS England
Page 2 · response
Published 27 April 2023
Open published response
4 Aug2022
Manchester South
Concerns raised1
1. Failure to provide timely bed access for elderly patients with hip fracture
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

James Robert Curry · Prevention of Future Deaths report

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

Report summary

James Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide timely bed access for elderly patients with hip fracture
Wider context from the report
“1. The Inquest heard that a lengthy wait for an elderly patient with a hip fracture on a trolley in the Emergency Department will impact their physiological reserves and add to their pain. In Mr Curry’s case, the Inquest heard that the prolonged wait was due to a shortage of beds within the Trust. That situation is still the case; 2. Mr Curry needed an orthopaedic bed to enable him to have the operation. The evidence was that a shortage of beds meant that he could not be placed in one and had to go to AMU. As a consequence on admission he did not receive the orthogeriatric care envisaged by NICE in their guidance; 3. The Inquest heard that the operation should have taken place earlier than it did under the NICE guidance. The Inquest was told that the NICE guidance is based on ensuring the best outcomes for elderly patients with fracture neck of femur and reducing mortality. It did not due to a shortage of capacity in the Trust. The Inquest heard that the Trust was regularly not able to operate in timescales compliant with the NICE guidance. ”
Source location
James Robert Curry · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 May2021
Brighton and Hove
Concerns raised1
1. Failure to transfer patients requiring higher-level care to appropriate critical care facilities
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

Mr. John Charles LOTT · 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 Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.

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 transfer patients requiring higher-level care to appropriate critical care facilities
Wider context from the report
“(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. ”
Source location
Mr. John Charles LOTT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Jul2020
Manchester South
Concerns raised1
1. Lack of surgical bed capacity delaying transfer from 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 7
1. Action
  Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.
  Stated by Department of Health and Social CareStated completed
2. Action
  Provide NHS Long Term Plan funding for primary and community care by 2023/24.
  Stated by Department of Health and Social CareStated planned
3. Action
  Roll out support for care home residents so more people can receive care in their communities.
  Stated by Department of Health and Social CareStated planned
1. Action
  Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, testing and PPE, medication supply, and next-day follow-up processes.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
4. Action
  Review community-based capacity to support discharges.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Samuel Garner · 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

Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of surgical bed capacity delaying transfer from the Emergency Department
Wider context from the report
“4. It was identified at an early stage that he would need a surgical bed and his care would be optimised in such a setting. There was a significant delay in moving him from the Emergency Department to a surgical ward due to lack of bed capacity within the Trust. ”
Source location
Samuel Garner · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020
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 NHS Long Term Plan funding for primary and community care by 2023/24.

Verbatim wording from the response
“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020
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
Roll out support for care home residents so more people can receive care in their communities.

Verbatim wording from the response
“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care home residents so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 3 · response
Published 1 October 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP also has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations, when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 3 · response
Published 1 October 2020
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 Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, testing and PPE, medication supply, and next-day follow-up processes.

Verbatim wording from the response
“As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 4 · response
Published 1 October 2020
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 additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020
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 community-based capacity to support discharges.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. Whilst we saw some initial improvements from this work, the second COVID wave is adding further pressure on acute hospital beds due to increased admissions and reduced bed availability as a result of infection, prevention control and staffing issues. Further work is underway to review community-based capacity to support discharges and to review elective care activity within hospitals. Reducing or suspending elective care work will help to provide additional capacity for patients, such as Samuel Garner, who have urgent care needs.”

Source location
2020-0145-Response-from-GMHSCP_Redacted.pdf
Page 5 · response
Published 1 October 2020
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
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0145-Response-from-DHSC_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
13 Jul2020
Manchester South
Concerns raised1
1. Lack of sufficient emergency department and inpatient bed capacity
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 11
1. Action
  Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
  Stated by Department of Health and Social CareStated completed
3. Action
  Introduce NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.
  Stated by Department of Health and Social CareStated planned
1. Action
  Provide NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.
  Stated by Department of Health and Social CareStated planned
2. Action
  Provide £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.
  Stated by Department of Health and Social CareStated completed
3. Action
  Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.
  Stated by Department of Health and Social CareStated planned
4. Action
  Implement NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
5. Action
  Implement a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
6. Action
  Develop more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
7. Action
  Implement the Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
8. Action
  Create additional community-based capacity to support discharge pathways and improve acute-care patient flow.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

John Cheetham · 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 Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

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 sufficient emergency department and inpatient bed capacity
Wider context from the report
“2. The evidence given to the inquest was that the Trust and all other acute hospitals in Greater Manchester were at that time facing significant challenges in terms of ED capacity. The capacity issues on that day were not one off but had been on going throughout December and continued through the winter months. As a result the ED was regularly overcrowded and elderly, vulnerable patients were regularly waiting for very long periods of time in unsuitable conditions in the ED. 3. The prolonged wait Mr Cheetham had was a result of lack of bed capacity. The inquest was told that this was due to delayed discharges of elderly in-patients back into the community because of challenges faced by adult social care. On the day that Mr Cheetham was waiting for a bed there were over 20 other patients in a similar position waiting for an in-patient bed. ”
Source location
John Cheetham · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue rolling out Urgent Treatment Centres, NHS 111 appointment booking and Same Day Emergency Care to manage urgent and emergency demand.

Verbatim wording from the response
“In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain Nightingale hospitals, their surge capacity and NHS use of independent-sector hospital capacity.

Verbatim wording from the response
“This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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 NHS 111 First to provide low-complexity care digitally and direct patients to appropriate settings more quickly.

Verbatim wording from the response
“Other elements of the NHS winter plan for 2020/21 include ‘NHS 111 First’ which will provide low complex care digitally and ensure those who need more care can receive it in the right setting more quickly, rather than waiting in A&E².”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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 NHS Trusts with a share of £300 million additional capital funding to upgrade facilities before winter.

Verbatim wording from the response
“NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £300million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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 £588 million to continue enhanced hospital-discharge arrangements over winter and maintain safe, timely discharge.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3billion funding for winter, an extra £588million has been confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 1 October 2020
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
Fund primary and community care, including national support for care homes, through the NHS Long Term Plan’s £4.5 billion annual commitment by 2023/24.

Verbatim wording from the response
“The NHS Long Term Plan commits funding worth £4.5billion per year by 2023/24 to be focused on primary and community care. This includes a national roll-out of support for care homes so more people can be looked after where they live. The NHS also aims to place therapy and social work teams at the beginning of the acute hospital pathway, setting an expectation that patients will have an agreed clinical care plan within 14 hours of admission, including an expected date of discharge.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 1 October 2020
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 NHS 111 First across Greater Manchester before winter to direct patients to appropriate services before Emergency Department attendance.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 a pre-Emergency Department triage and streaming system before winter to direct patients to appropriate services.

Verbatim wording from the response
“The onset of the COVID 19 crisis delayed the transformation programme until more recently where we have refreshed our planning work and agreed to rapidly implement new models of care during September and October this year (ahead of winter). The new approach will incorporate two elements:”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 more sophisticated Urgent and Emergency Care Operational Hub methods to manage demand, patient flow and Emergency Department crowding.

Verbatim wording from the response
“It is also worth noting that GMHSCP has a Greater Manchester Urgent and Emergency Care Operational Hub, which is designed to provide real time support to local systems by monitoring and managing patient flow. The hub has a near to real time data feed from all acute hospital sites, which it uses to support decision making around deflection of ambulances to alternative destinations when a hospital emergency department is showing signs of pressure. The hub also supports the management of discharges from hospital and repatriations between hospital sites (in and out of the GM area). The hub is under constant development and is working closely with systems to develop more sophisticated methods of managing demand to reduce the likelihood of emergency department crowding even further and proactively managing flow to prevent blockages.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 Greater Manchester Discharge to Assess pathway, including a single referral form, timely triage, testing and PPE compliance, medication supplies and next-day follow-up.

Verbatim wording from the response
“Point 3 – hospital bed capacity and the discharge of patients”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 2 · response
Published 1 October 2020
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 additional community-based capacity to support discharge pathways and improve acute-care patient flow.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. As a result, there has been a significant reduction in the proportion of long stay patients and acute hospital bed occupancy levels across all Greater Manchester sites. This has helped to improve flow from Emergency Departments and therefore helped reduce crowding. Bed occupancy is currently on average 83% across Greater Manchester, which is at least 10% lower than the same period last year.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 3 · response
Published 1 October 2020
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
Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 1 · response
Published 1 October 2020
Open published response
11 Jul2018
Brighton and Hove
Concerns raised1
1. Failure to arrange early transfer to an appropriate specialist hospital
This report raised 6 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

Rita Elizabeth GILES · 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

Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to arrange early transfer to an appropriate specialist hospital
Wider context from the report
“(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork. (2) The Trust’s own Transfer Policy not adhered too in any respect. (3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later. (4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement. There was a failure to appreciate that as she was already septic when she came in the matter was urgent. From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round. ”
Source location
Rita Elizabeth GILES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 May2017
North Wales (East and Central)
Concerns raised1
1. Failure of hospital patient flow and delayed transfer of care processes
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 15
1. 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
2. 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
3. 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
1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
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
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
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
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
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
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
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 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
10 Mar2017
East London
Concerns raised1
1. Failure of porters to collect post-procedure patients
This report raised 7 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 Anna Teresa Walker · 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 Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.

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 of porters to collect post-procedure patients
Wider context from the report
“2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust. II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure). III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring. ”
Source location
Mrs Anna Teresa Walker · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Nov2016
Portsmouth and South East Hampshire
Concerns raised1
1. Failure to implement consultants' requests for patient transfer to specialist wards
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.
  Stated by Portsmouth Hospitals University NHS TrustStated completed
Respondent positions 1
1. Position
  Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.
  Stated by Portsmouth Hospitals University NHS TrustDisputes the concern
AI-generated summary

Christopher Allen MacMORLAND · 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

Christopher Allen MacMORLAND was admitted to hospital with feeding difficulties and later readmitted with abdominal pain and distension; his condition deteriorated and he died on 5 December 2015. The substantive concern was that, despite five requests by consultant gastroenterologists, he was not transferred to a specialist gastroenterology ward, and evidence indicated that such a ward might have affected the outcome.

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 implement consultants' requests for patient transfer to specialist wards
Wider context from the report
“I was told in evidence at the Inquest that despite Mr MacMORLAND being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence I heard, I am of the opinion that he could have benefited from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. I was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented. ”
Source location
Christopher Allen MacMORLAND · 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
Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.

Verbatim wording from the response
“By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full.”

Source location
2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 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
Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.

Verbatim wording from the response
“The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised.”

Source location
2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017
Open published response
14 Dec2015
Central and South East Kent
Concerns raised1
1. Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
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 2
1. Action
  Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated completed
2. Action
  Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
  Stated by Guy'S and St Thomas' NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
  Stated by Guy'S and St Thomas' NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Kevin John Gilbert · 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

Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.

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 accepting transfer of suspected aortic dissection patients while awaiting CT imagery
Wider context from the report
“• Given that Mr Gilbert was presenting at William Harvey Hospital as an acute emergency requiring specialist surgery at a tertiary centre and that his diagnosis of suspicion made on presenting clinical symptoms by a Consultant in Accident and Emergency medicine which was confirmed by CT scan, it was not reasonable for ████████ to rely on his understanding of the procedure of accepting such patients and wait for the CT imagery before agreeing that he could be transferred. ”
Source location
Kevin John Gilbert · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.

Verbatim wording from the response
“In January 2015, shortly after Mr Gilbert died, the referring consultant wrote to Mr Avlonitis, consultant cardiothoracic surgeon and raised concerns about the delay in transfer. Following receipt of the letter Mr Avlonitis wrote to all registrars in the Cardiothoracic Department to clarify the department’s process for accepting dissection referrals. He confirmed that all such referrals must be discussed immediately with the duty consultant and any decision to ask to review CT imagery before transfer could only be made by a consultant. The text of the email is shown below.”

Source location
Kevin-GILBERT-Response
Page 2 · response
Published 14 December 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
Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.

Verbatim wording from the response
“I would also like to make the Coroner aware of a more recent change to the management of dissection referrals at the Trust. It has always been the case that there is an ‘open door’ policy for leaking abdominal aortic aneurysms, meaning they are accepted by the vascular surgical team for immediate transfer if clinically appropriate, with a guarantee that theatre and critical care capacity will be made available. This approach has now been extended to include dissections of the ascending aorta and arch such as suffered by Mr Gilbert. Therefore, from May 2016, any such referral to this Trust will be discussed immediately with the duty consultant cardiac surgeon (as outlined above), who will then be able to authorise immediate transfer if clinically indicated, with that same guarantee that theatre and critical care capacity will be made available.”

Source location
Kevin-GILBERT-Response
Page 2 · response
Published 14 December 2015
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
Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.

Verbatim wording from the response
“The Trust is absolutely committed to learning from incidents and about how care can be improved and delivered more effectively. I am confident that following the email, and the reinforcement of the message by consultant staff, that all junior staff are completely clear that dissection referrals must be reviewed immediately by the duty consultant and they understand that the transfer decision must be made by a consultant.”

Source location
Kevin-GILBERT-Response
Page 2 · response
Published 14 December 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to promptly transfer patients to an available ward bed or appropriate alternative place

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

Concerns raised1

Failure to provide timely bed access for elderly patients with hip fracture

Concerns raised1

Failure to transfer patients requiring higher-level care to appropriate critical care facilities

Concerns raised1

Lack of surgical bed capacity delaying transfer from 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.7

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

Concerns raised1

Lack of sufficient emergency department and inpatient bed capacity

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.11

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

Concerns raised1

Failure to arrange early transfer to an appropriate specialist hospital

Actions described in response 2

Actions described in response 7

Respondent positions 1

Actions described in response 11

Respondent positions 1