Recurring concern

Failure to provide timely suitable onward care placements for patients ready for hospital discharge

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First reported 28 Nov 2017•Latest report 18 Jun 2026

Definition

What this concern includes

Includes deficiencies in the discharge and onward-placement process where suitable care-home, nursing, social-care or community provision is unavailable, difficult to identify, arrange or fund, or otherwise fails to enable timely discharge of patients ready to leave acute hospital care.

Not included

Excludes shortages or placement failures unrelated to patients ready for discharge from acute hospital care unless the report directly connects them to this discharge and onward-care condition.
Excludes failures concerning the clinical treatment, supervision or safety of patients who appropriately remain in acute hospital care.
Excludes generic social-care, commissioning or funding deficiencies that are not directly tied to obtaining suitable onward care for a patient ready for hospital discharge.
Excludes unsuitable school, mental-health detention or other placements where the issue is not hospital discharge to onward care.

Reports: 28
Individual concerns: 30
Date range: 2017–2026
Stated actions: 97

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 Care22

NHS Greater Manchester Integrated Care Board4

Betsi Cadwaladr University LHB3

Conwy County Borough Council3

Denbighshire County Council3

Flintshire County Council3

Gwynedd Council3

Isle of Anglesey County Council3

Welsh Ambulance Services NHS Trust3

Wrexham County Borough Council3

Care Quality Commission2

Greater Manchester Health and Social Care Partnership2

Kent County Council2

Medway Council2

NHS England2

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.

18 Jun2026
Cornwall and Isles of Scilly
Concerns raised1
1. Insufficient social care provision for onward discharge support
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 2
1. Action
  Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.
  Stated by Department of Health and Social CareStated completed
2. Action
  Work with health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Geoffrey Gordon Fuller · Prevention of Future Deaths report

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

Report summary

Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient social care provision for onward discharge support
Wider context from the report
“1. The court found there was insufficient bed availability on acute wards which was attributable to significant numbers of patients in hospital with no reason to reside (NCTR), these being patients who are medically optimised but cannot be discharged due to lack of onward care support. 2. On the day of the ambulance delay, 7 July 2025, almost 20% of patients in RCHT were recorded as NCTR. 3. The court noted the main cause for the numbers of NCTR patients was insufficient social care provision, whether commissioned by social services or NHS. 4. Investigations in 2022 and 2023 by SWAST and the Healthcare Safety Investigation Branch (HSIB) found a direct link between ambulance delays and inadequate social care provision. The court noted the SWAST systems report which found… “…..there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside ambulances and Emergency Departments.” 5. This court has previously noted data indicating significant vacancies in social care posts in Cornwall are vacant reflecting the national picture of nationwide vacant direct social care posts. [see previous PFD reports on this subject] 6. The court noted that the NHS does not carry responsibility for the recruitment and retention of social care staff or any broad obligation to promote the social care market. 7. The HSSIB report referred to the fact that the organisations immediately required to deal with ambulance delays are ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not have control over the services primarily responsible for ambulance delays, namely social care provision and support. They are unable to influence the whole-system and therefore carry risks that they cannot wholly mitigate or manage. 8. The court noted the HSSIB report which states that delayed discharges (and consequent ambulance delays) are a national issue which is attributed to a whole system failure of health and social care. The court noted the HSSIB investigation’s first safety recommendation is an urgent ‘whole system’ response to reduce patient harm. ”
Source location
Geoffrey Gordon Fuller · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish national clinical standards for emergency departments, acute pathways and discharge to improve flow and safer emergency care.

Verbatim wording from the response
“This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 3 September 2026
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 health and care partners to improve discharge arrangements, strengthen service integration and ensure safe, timely and appropriate care.

Verbatim wording from the response
“We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 3 September 2026
Open published response
10 Feb2026
Kent and Medway
Concerns raised1
1. Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 19
1. Action
  Recruit staff and improve referral processes to reduce Kent Enablement at Home discharge times.
  Stated by Kent County CouncilStated completed
2. Action
  Improve referral processes for the short-term pathway to reduce transfer-of-care times.
  Stated by Kent County CouncilStated completed
3. Action
  Work with the trust to identify themes and trends causing hospital-discharge delays.
  Stated by Kent County CouncilStated in progress
1. Action
  Review Short Term Pathways practice and processes.
  Stated by Kent County CouncilStated in progress
2. Action
  Review the commissioning of hospital-discharge services.
  Stated by Kent County CouncilStated in progress
3. Action
  Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting to the ICB.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
4. Action
  Increase short-term home-care capacity so more patients can be safely discharged with necessary support.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
5. Action
  Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
  Stated by NHS Kent and Medway Integrated Care BoardStated in progress
6. Action
  Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
  Stated by NHS Kent and Medway Integrated Care BoardStated planned
7. Action
  Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential or nursing placements, with weekly performance reporting to the ICB.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
8. Action
  Increase short-term care-at-home capacity to enable safe discharge with necessary support, overseen through the Medway System Discharge Group.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
9. Action
  Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
  Stated by NHS Kent and Medway Integrated Care BoardStated in progress
10. Action
  Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
  Stated by NHS Kent and Medway Integrated Care BoardStated planned
11. Action
  Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.
  Stated by Medway CouncilStatus unclear
12. Action
  Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.
  Stated by Medway CouncilStated completed
13. Action
  Introduce 24-hour care-at-home services for people with high needs to return home safely where appropriate.
  Stated by Medway CouncilStatus unclear
14. Action
  Recruit an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.
  Stated by Medway CouncilStated completed
15. Action
  Establish a dedicated brokerage team to source care for people ready for discharge from hospital or community settings.
  Stated by Medway CouncilStated completed
16. Action
  Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.
  Stated by Medway CouncilStated in progress
Respondent positions 1
1. Position
  Discharge delays cannot be attributed solely to adult social care or community health services because they arise from interdependent system-wide factors.
  Stated by Medway CouncilDisputes the concern
AI-generated summary

Barbara Wingate · Prevention of Future Deaths report

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

Report summary

Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report
“Evidence heard at the inquest revealed that the resuscitation department where Mrs Wingate should have been admitted was full and the evidence indicated that this was and is almost a daily occurrence at the Trust. The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day the court heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital. The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute. This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death as seen in this case and there is clearly a risk of death for others requiring clinical care in an acute hospital. ”
Source location
Barbara Wingate · Prevention of Future Deaths report
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
Recruit staff and improve referral processes to reduce Kent Enablement at Home discharge times.

Verbatim wording from the response
“During this period Kent Enablement at Home were experiencing a high number of vacancies within the team, with a 30% vacancy factor which impacted on the referral to discharge time. A recruitment campaign and efficiencies created within referral processes has reduced this time to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48 hour timescale for discharge back to a person’s own home.”

Source location
Response from Kent County Council
Page 2 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve referral processes for the short-term pathway to reduce transfer-of-care times.

Verbatim wording from the response
“A small number of people are discharged to a short-term bed where they receive a period of enablement and/or assessment of their longer-term care and support needs. The majority of these people are discharged to KCC’s Adult Short Stay Services which are in-house enablement beds. During the time that Mrs Wingate died, the average time for discharge to be facilitated from the time of referral to the Short-Term Pathways team was 5.3 days. Improvements have been made to the referral processes for this pathway, and the current average transfer of care time is 3 days.”

Source location
Response from Kent County Council
Page 2 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with the trust to identify themes and trends causing hospital-discharge delays.

Verbatim wording from the response
“Despite the improvements made to the length of stay for people with No Criteria to Reside attributable to KCC, our data clearly shows that 50% of referrals experience delays beyond the control of KCC. The main reasons for these delays are availability of discharge documentation, medication, and transport availability. These delays are reported in Medway Hospital’s No”

Source location
Response from Kent County Council
Page 2 · response
Published 13 February 2026
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 Short Term Pathways practice and processes.

Verbatim wording from the response
“KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.”

Source location
Response from Kent County Council
Page 3 · response
Published 13 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the commissioning of hospital-discharge services.

Verbatim wording from the response
“KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.”

Source location
Response from Kent County Council
Page 3 · response
Published 13 February 2026
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 the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting to the ICB.

Verbatim wording from the response
“The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.”

Source location
2026-0088 - Response from Kent and Medway ICB
Page 2 · response
Published 13 February 2026
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 short-term home-care capacity so more patients can be safely discharged with necessary support.

Verbatim wording from the response
“Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:”

Source location
2026-0088 - Response from Kent and Medway ICB
Page 2 · response
Published 13 February 2026
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 access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.

Verbatim wording from the response
“3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.”

Source location
2026-0088 - Response from Kent and Medway ICB
Page 3 · response
Published 13 February 2026
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.

Verbatim wording from the response
“3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.”

Source location
2026-0088 - Response from Kent and Medway ICB
Page 3 · response
Published 13 February 2026
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 the Medway Care Transfer Hub as the single coordination and escalation point for new residential or nursing placements, with weekly performance reporting to the ICB.

Verbatim wording from the response
“The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.”

Source location
Response from Kent and Medway Integrated Care Board
Page 2 · response
Published 13 February 2026
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 short-term care-at-home capacity to enable safe discharge with necessary support, overseen through the Medway System Discharge Group.

Verbatim wording from the response
“2. Expanding the Home First/short-term support capacity (Pathway 1, Discharge home with short-term support) – capacity for short-term care at home has been increased so more people can leave hospital safely with the necessary support. Oversight of capacity, flow and performance is provided through the Medway System Discharge Group, a local MDT approach supporting discharge.”

Source location
Response from Kent and Medway Integrated Care Board
Page 3 · response
Published 13 February 2026
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 access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.

Verbatim wording from the response
“3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.”

Source location
Response from Kent and Medway Integrated Care Board
Page 3 · response
Published 13 February 2026
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.

Verbatim wording from the response
“3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.”

Source location
Response from Kent and Medway Integrated Care Board
Page 3 · response
Published 13 February 2026
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
Recommission the Integrated Care and Reablement Service to increase community health bed capacity and support acute-care discharge.

Verbatim wording from the response
“A range of actions have been implemented or are in progress these are:”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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
Commission eight assessment beds for people awaiting discharge who need therapy to regain independence before returning home.

Verbatim wording from the response
“The Council has commissioned eight assessment beds for individuals ready for discharge but requiring further therapy to support independence before returning home.”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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 24-hour care-at-home services for people with high needs to return home safely where appropriate.

Verbatim wording from the response
“A range of actions have been implemented or are in progress these are:”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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 an independent commissioner to identify provider barriers to accepting discharged patients and support increased complex-needs residential and nursing capacity.

Verbatim wording from the response
“The Council has recruited an independent commissioner to work with care providers to understand barriers to accepting discharged patients and to support increased residential and nursing home capacity, particularly for those with complex needs.”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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 dedicated brokerage team to source care for people ready for discharge from hospital or community settings.

Verbatim wording from the response
“The Council has established a dedicated brokerage team focused solely on sourcing care for individuals ready to be discharged from hospital or community settings.”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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
Progress governance processes to develop a new 80-bed care home addressing longer-term structural capacity constraints.

Verbatim wording from the response
“Medway Council is progressing through governance processes to develop a new 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints”

Source location
Response from Medway Council
Page 2 · response
Published 13 February 2026
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
Discharge delays cannot be attributed solely to adult social care or community health services because they arise from interdependent system-wide factors.

Verbatim wording from the response
“At any given time, it would be erroneous to conclude delays in hospital discharge can be attributed solely to adult social care or community health services. Evidence from across Medway demonstrates that delays arise from a range of interdependent factors across the health and social care system. These include:”

Source location
Response from Medway Council
Page 1 · response
Published 13 February 2026
Open published response
10 Feb2026
Kent and Medway
Concerns raised1
1. Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients
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 19
1. Action
  Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
2. Action
  Increase short-term home-care capacity so patients can leave hospital safely with necessary support.
  Stated by NHS Kent and Medway Integrated Care BoardStated completed
3. Action
  Expand access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.
  Stated by NHS Kent and Medway Integrated Care BoardStated in progress
1. Action
  Establish a bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.
  Stated by NHS Kent and Medway Integrated Care BoardStated planned
2. Action
  Complete recruitment activity to increase Short Term Pathways Team capacity and reduce discharge delays.
  Stated by Kent County CouncilStated completed
3. Action
  Improve Kent Enablement at Home referral processes to reduce time from discharge referral to home-care support.
  Stated by Kent County CouncilStated completed
4. Action
  Improve referral processes for short-term bed pathways to reduce transfer-of-care times.
  Stated by Kent County CouncilStated completed
5. Action
  Work with the hospital trust to identify themes and trends causing delays in hospital discharge.
  Stated by Kent County CouncilStated in progress
6. Action
  Review Short-Term Pathways practices and processes.
  Stated by Kent County CouncilStated in progress
7. Action
  Review the commissioning of hospital discharge services.
  Stated by Kent County CouncilStated in progress
8. Action
  Continue applying Discharge to Assess and home-first principles to support timely discharge into home-based services.
  Stated by Kent County CouncilStated completed
9. Action
  Recommission the Integrated Care and Reablement Service to increase community health bed capacity for hospital discharge.
  Stated by Medway CouncilStated completed
10. Action
  Commission eight assessment beds to provide therapy and support independence for people awaiting discharge home.
  Stated by Medway CouncilStated completed
11. Action
  Introduce 24-hour home care for people with high care and support needs where returning home is safe and appropriate.
  Stated by Medway CouncilStated completed
12. Action
  Recruit an independent commissioner to engage private care providers about hospital discharge capacity.
  Stated by Medway CouncilStated completed
13. Action
  Investigate private providers’ barriers to accepting discharge-ready residents and identify ways to increase complex-needs residential and nursing capacity.
  Stated by Medway CouncilStated in progress
14. Action
  Appoint a system-wide hospital discharge care coordinator to provide strategic oversight, coordination and escalation across organisational boundaries.
  Stated by Medway CouncilStated completed
15. Action
  Create a dedicated brokerage team to source care for people ready for discharge from hospital and community health settings.
  Stated by Medway CouncilStated completed
16. Action
  Progress governance approval to develop an 80-bed care home addressing longer-term capacity constraints.
  Stated by Medway CouncilStated in progress
Respondent positions 1
1. Position
  Discharge delays are not wholly attributable to adult social care or community health services; they result from interdependent whole-system factors.
  Stated by Medway CouncilDisputes the concern
AI-generated summary

Liam Andrew SUTTON · 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

Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.

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 arranging timely appropriate community care packages or alternative placements for medically fit patients
Wider context from the report
“The court heard in the inquest revealed that the resuscitation department where Mr Sutton was admitted was busy and the evidence indicated that this was and is almost a daily occurrence at the Trust. Mr Sutton remained in the Emergency department resuscitation area for longer than 24 hours and should instead have been transferred to a suitable bed in the hospital. The Intensivist who gave evidence was clear that he should have been transferred to the High Dependency/ Intensive Care department and that patients who are admitted in a timely manner have a much better chance of survival. This also means that bays in the resuscitation department are not free to admit or attend to new acutely ill patients arriving at the hospital. The court heard that the main issue is trying to discharge a patient to a suitable area in the hospital to free up a cubicle or bay in the resuscitation department. This in turn is due to beds being occupied by patients who are medically fit to be discharged. On any given day we heard that up to a third of the hospital beds can be filled with patients who are fit to leave hospital. The court heard that the main delay is in discharging patients to appropriate settings or placements and the Trust have taken all steps they can internally to improve the flow of patients through the hospital. From the evidence the court heard it would appear that those responsible for providing care in the community including both the social care providers and the community healthcare providers are not providing either timely appropriate care packages in the patient's home or a bed in an alternative placement be that a nursing home or residential home placement. The evidence suggested that where patients were self funding the delays in discharge were less acute. This means patients are kept in hospital for longer and thus are more at risk of contracting hospital acquired illnesses themselves which could lead to their own death but are also blocking beds which are needed to treat patients who require acute care in a suitable setting. This is leading to patients being kept longer in the emergency department and reducing available space to receive new critically ill patients. Both of these options can lead to death and there is clearly a risk of death for others requiring clinical care in an acute hospital ”
Source location
Liam Andrew SUTTON · 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
Operate the Medway Care Transfer Hub as the single coordination and escalation point for new residential and nursing placements, with weekly performance reporting.

Verbatim wording from the response
“The Medway Care Transfer Hub now acts as the single coordination and escalation point for the Local Authority and Health to support patients requiring new residential or nursing placements. This ensures consistent, person-centred decision making and removes delays associated with variable processes. The Hub provides weekly reports to the ICB on performance, issues, and escalations.”

Source location
Response from Kent and Medway ICB
Page 2 · response
Published 16 February 2026
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 short-term home-care capacity so patients can leave hospital safely with necessary support.

Verbatim wording from the response
“Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:”

Source location
Response from Kent and Medway ICB
Page 3 · response
Published 16 February 2026
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 access to short-term community rehabilitation beds to improve onward flow for patients no longer requiring acute inpatient care.

Verbatim wording from the response
“Over the last six months we have taken coordinated actions with Medway Council, Medway Foundation NHS Trust (MFT) and wider system partners to make several improvements to the main, nationally agreed pathways, which are used by the hospital for discharge. The pathways have been developed to address individual patient need and circumstances:”

Source location
Response from Kent and Medway ICB
Page 3 · response
Published 16 February 2026
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 bed-coordination brokerage function for timely allocation of short-term community rehabilitation beds by the third quarter of 2026.

Verbatim wording from the response
“3. Increasing access to short-term community rehabilitation beds (Pathway 2) and reducing transfer delays – work is underway to expand access to short-term community rehabilitation beds improving onward flow for patients who no longer need acute inpatient care. A new bed-coordination (brokerage) function will be operational by quarter three of 2026 ahead of winter with clear accountability for timely allocation and progress monitored monthly through ICB assurance routes.”

Source location
Response from Kent and Medway ICB
Page 3 · response
Published 16 February 2026
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 recruitment activity to increase Short Term Pathways Team capacity and reduce discharge delays.

Verbatim wording from the response
“During this period, the team was running with a 20% vacancy factor. The vacancy factor combined with the increase in demand led to an increase in the time from referral to discharge for these people which was an average of 3.8 days during the week that Mr Sutton died. A recruitment campaign and efficiencies created within Kent Enablement at Home’s referral processes has reduced the timescale for people discharged with home care support to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48-hour timescale for discharge back to a person’s own home.”

Source location
Response from Kent County Council
Page 2 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve Kent Enablement at Home referral processes to reduce time from discharge referral to home-care support.

Verbatim wording from the response
“During this period, the team was running with a 20% vacancy factor. The vacancy factor combined with the increase in demand led to an increase in the time from referral to discharge for these people which was an average of 3.8 days during the week that Mr Sutton died. A recruitment campaign and efficiencies created within Kent Enablement at Home’s referral processes has reduced the timescale for people discharged with home care support to 1.8 days. This has been consistent for the last three months and is in line with key performance indicators set by Medway Hospital of a 48-hour timescale for discharge back to a person’s own home.”

Source location
Response from Kent County Council
Page 2 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Improve referral processes for short-term bed pathways to reduce transfer-of-care times.

Verbatim wording from the response
“A small number of people are discharged to a short-term bed where they receive a period of enablement and/or assessment of their longer-term care and support needs. The majority of these people are discharged to KCC’s Adult Short Stay Services which are in-house enablement beds. During the month of December 2024 when Mr Sutton died, KCC identified one person who required support from this pathway and the time for discharge to be facilitated from the time of referral was 6 days. Since the time of Mr Sutton’s death, improvements have been made to the referral processes for this pathway, and the current average transfer of care time is 3 days.”

Source location
Response from Kent County Council
Page 2 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with the hospital trust to identify themes and trends causing delays in hospital discharge.

Verbatim wording from the response
“transport availability. These delays are reported in Medway Hospital’s No Criteria to Reside report and KCC continue to work with the trust in identifying themes and trends that delay hospital discharge.”

Source location
Response from Kent County Council
Page 3 · response
Published 16 February 2026
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 Short-Term Pathways practices and processes.

Verbatim wording from the response
“KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short-Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.”

Source location
Response from Kent County Council
Page 3 · response
Published 16 February 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the commissioning of hospital discharge services.

Verbatim wording from the response
“KCC continues to review hospital discharge practice and guidance in collaboration with system partners. The local authority is currently undergoing a review of the Short-Term Pathways practice and processes, and the commissioning of hospital discharge services. KCC will continue to focus on the principles of Discharge to Assess and home first with the ambition of further increasing timely discharges into Pathway 1 home-based services.”

Source location
Response from Kent County Council
Page 3 · response
Published 16 February 2026
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 applying Discharge to Assess and home-first principles to support timely discharge into home-based services.

Verbatim wording from the response
“At the time of Mr Sutton’s death, KCC operated a Discharge to Assess model and home first approach in line with national statutory discharge guidance, Hospital discharge and community support guidance - GOV.UK. The Local Authority continues to operate this model.”

Source location
Response from Kent County Council
Page 1 · response
Published 16 February 2026
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
Recommission the Integrated Care and Reablement Service to increase community health bed capacity for hospital discharge.

Verbatim wording from the response
“Commissioning action: The council has recommissioned the Integrated Care and Reablement Service (ICRS). This will increase community health bed capacity to support discharge from acute care.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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
Commission eight assessment beds to provide therapy and support independence for people awaiting discharge home.

Verbatim wording from the response
“Commissioning action: The council has commissioned 8 assessment beds to enable people who are ready to be discharged but not quite ready to go home to receive therapy and support them to independence.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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 24-hour home care for people with high care and support needs where returning home is safe and appropriate.

Verbatim wording from the response
“Commissioning action: The council has introduced 24-hour care at home to enable people who have high care and support needs to go home, rather than to a care home where it is safe and appropriate.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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 an independent commissioner to engage private care providers about hospital discharge capacity.

Verbatim wording from the response
“Market engagement: The council has recruited an independent commissioner to work with private care providers to better understand why they are not accepting residents who are ready to be discharged from hospital, to determine how we can increase residential and nursing home capacity, particularly for people with complex needs.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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
Investigate private providers’ barriers to accepting discharge-ready residents and identify ways to increase complex-needs residential and nursing capacity.

Verbatim wording from the response
“Market engagement: The council has recruited an independent commissioner to work with private care providers to better understand why they are not accepting residents who are ready to be discharged from hospital, to determine how we can increase residential and nursing home capacity, particularly for people with complex needs.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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
Appoint a system-wide hospital discharge care coordinator to provide strategic oversight, coordination and escalation across organisational boundaries.

Verbatim wording from the response
“System Leadership: A single care co-ordinator for hospital discharge has been appointed to operate on a system basis and reports directly to the Director of Adult Social Services (DASS) providing strategic oversight, coordination and escalation across organisational boundaries and to the Chief Operating Officer at Medway Foundation Trust from an operational perspective.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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 dedicated brokerage team to source care for people ready for discharge from hospital and community health settings.

Verbatim wording from the response
“Sourcing Care: Medway Council has created a dedicated brokerage team to find care for people ready to be discharged from hospital and community health settings. This means that the team is not balancing the need to source care for people in the community at the same time.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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
Progress governance approval to develop an 80-bed care home addressing longer-term capacity constraints.

Verbatim wording from the response
“Long term capacity development: Medway Council is progressing through the governance process to develop an 80-bed care home, recognising ongoing system challenges. While a longer-term intervention, this reflects the Council’s seriousness in addressing structural capacity constraints.”

Source location
Response from Medway Council
Page 2 · response
Published 16 February 2026
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
Discharge delays are not wholly attributable to adult social care or community health services; they result from interdependent whole-system factors.

Verbatim wording from the response
“At any given time, delays in discharge are not wholly attributable to adult social care or community health services. Evidence across Medway demonstrates that delays arise from a combination of interdependent factors across the health and social care system. These include acute hospital internal flow, bed availability, discharging planning processes, clinical decision making and escalation arrangements, alongside capacity constraints in community and social care provision. While the acute trust has implemented a range of measures to improve patient flow, it would not be accurate to conclude that all possible internal actions have been exhausted. Improvements continue at a system interface level, and this position is recognised across partners and underpins the ongoing whole system oversight arrangements described below.”

Source location
Response from Medway Council
Page 1 · response
Published 16 February 2026
Open published response
10 Jul2025
Manchester South
Concerns raised1
1. Lack of suitable social care placements causing delayed hospital discharges
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Continue the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Provide £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.
  Stated by Department of Health and Social CareStated planned
1. Action
  Provide over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.
  Stated by Department of Health and Social CareStated planned
AI-generated summary

Doreen Swann · Prevention of Future Deaths report

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

Report summary

Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of suitable social care placements causing delayed hospital discharges
Wider context from the report
“1. The inquest heard evidence that Doreen Swann was only in hospital at the point of her fall because her discharge had been delayed due to a shortage of a suitable social care placement. The evidence was that nursing/caring for high falls risk patients in an acute setting is challenging and resource intensive. 2. The evidence given to the inquest was that this delayed discharge and the ongoing risk it presents was not an isolated incident at TGH -as an example the evidence given was that there were regularly 30 plus patients with a delayed discharge over 3 weeks due to a lack of social care beds .The evidence indicated that this challenge was not unique to Tameside. 3. The evidence indicated that managing a falls risk and the consequential risk to life is better managed outside an acute setting once the clinical need for a hospital stay has passed. 4. Delayed discharges such as Doreen Swann’s reduces the availability of beds for other patients and creates a knock-on impact across the hospital particularly in relation to the Emergency Department. ”
Source location
Doreen Swann · Prevention of Future Deaths report
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
Continue the Tameside patient-flow and discharge improvement programme, including front-door process mapping and monthly monitoring of delivery targets.

Verbatim wording from the response
“As part of a system led improvement programme, there is a continued focus on patient flow and discharge in Tameside covered by the Trust Deputy Chief Operating Officer, Trust Deputy Chief Nurse, and Director of Adult Services for the Local Authority. Progress against the delivery targets within this improvement programme is monitored through a monthly programme group which was established in April 24 and has delivered a significant reduction in patients with a No Criteria to Reside (NCTR) status over recent months. This means that patients who are medically fit for discharge are being discharged to the right place much quicker. This includes process-mapping to support front-door processes to enable deflection to other services.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 17 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain weekly multidisciplinary oversight of length of stay and delayed transfers to review hospital appropriateness and support discharge.

Verbatim wording from the response
“In terms of oversight of discharge planning and patients with NCTR, the Trust’s Chief Operating Officer chairs a weekly meeting to review Length of Stay and Delayed Transfers of Care. Membership includes local stakeholders and the Director of Adult Services to review each patient and ensure appropriateness of care within a hospital setting and aim to support discharge.”

Source location
Response from Greater Manchester Integrated Care
Page 2 · response
Published 17 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide £9 billion through the Better Care Fund to support integrated health and social care and shared discharge-planning accountability.

Verbatim wording from the response
“The Better Care Fund (BCF) is a key part of our plan to address these delays, particularly when they are caused by a shortage of suitable social care, by supporting Integrated Care Boards and local authorities to deliver joined-up health and social care. This year, the BCF will provide £9 billion to help ensure patients receive the right care in the right place, with shared accountability for discharge planning.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 17 July 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide over £4 billion in additional adult social care funding by 2028–29 to help local authorities improve services and meet statutory duties.

Verbatim wording from the response
“Additionally, the Spending Review includes over £4 billion additional funding for adult social care by 2028-29, compared to 2025-26, helping local authorities improve services and meet their duties under the Care Act 2014.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 17 July 2025
Open published response
29 May2025
North Wales (East and Central)
Concerns raised1
1. Lack of social care and community hospital capacity for discharge and onward bed availability
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 1
1. Action
  Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.
  Stated by Welsh GovernmentStated completed
Respondent positions 3
1. Position
  Welsh Ministers set strategic expectations but are not responsible for delivering health services.
  Stated by Welsh GovernmentOutside remit
1. Position
  Health boards are responsible for planning, commissioning and delivering local health services within the national policy framework.
  Stated by Welsh GovernmentRedirects responsibility
2. Position
  Health boards are responsible for ensuring ambulance handovers occur reliably and that receiving hospitals have sufficient capacity.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Jeanette Sidlow Beech · Prevention of Future Deaths report

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

Report summary

Jeanette Sidlow Beech, who had a history of alcohol withdrawal-related seizures, became unwell at home on 2 August 2024 and died there on 3 August 2024 after suffering a seizure and cardiac arrest. An ambulance took 15 hours and 13 minutes to attend, by which time resuscitation efforts were unsuccessful. The report raises concerns about ambulance response and hospital handover delays, linked to wider pressures involving hospital capacity, social care and community hospital provision.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of social care and community hospital capacity for discharge and onward bed availability
Wider context from the report
“a. It took a total period of 15 hours and 13 minutes for an ambulance to attend upon Jeanette, by which time she was in cardiac arrest and resuscitation efforts were unsuccessful. b. Whilst evidence was received and heard during the Inquest that efforts have been and are still being taken by WAST to improve the situation regarding ambulance delays, there remains significant concerns with Hospital handover delays. c. It is well known, having heard evidence in previous Inquests, that the causes of ambulance delays are multifactorial. They do not rest solely with WAST. d. Many Coroners in Wales have issued many Reports over many years on the time it takes for ambulances to attend on the background of various reasons. e. It appears to remain the case that the lack of social care provision and/or Community Hospitals means that those fit to be discharged from district general hospitals are not discharged and those in Emergency Departments or on ambulances outside Emergency Departments are unable to be provided with a bed in the hospitals such that ambulances remain outside Emergency Departments for hours. Evidence was heard that between 2nd and 3rd August 2024 at Betsi Cadwaladr University Local Health Board the longest delay in ambulance handover times were in excess of 6 hours and 7 hours. f. The issues identified are pertinent to WAST, the Health Board and Local Authorities. g. There appears to be no improvement in these ongoing issues and I am particularly concerned that lives are being put at risk, and that deaths will occur into the future and will continue to occur where this situation persists. ”
Source location
Jeanette Sidlow Beech · Prevention of Future Deaths report
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
Make £2.7 million available for local improvement plans within £35.5 million supporting regional community, admission-avoidance and integrated social-care solutions.

Verbatim wording from the response
“We have made an additional £2.7m available to the health board this year to support delivery of local improvement plans. This is part of £35.5m to support the health board and the North Wales Regional Partnership Board to safely manage more people in the community; to avoid ambulance transport and admission to hospital; and deliver integrated solutions with social care services to improve patient flow through hospitals. The impact made by the region is being closely monitored.”

Source location
Response from Welsh Government
Page 4 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Welsh Ministers set strategic expectations but are not responsible for delivering health services.

Verbatim wording from the response
“Welsh Ministers set the strategic context and expectations for health and care services in Wales and hold NHS organisations accountable for fulfilling their statutory duties. Welsh Ministers are not responsible for the delivery of health services.”

Source location
Response from Welsh Government
Page 1 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Health boards are responsible for planning, commissioning and delivering local health services within the national policy framework.

Verbatim wording from the response
“Health boards and NHS trusts are responsible for planning, commissioning and delivering services for the population of their local areas, in line with the national policy framework set by Welsh Ministers.”

Source location
Response from Welsh Government
Page 1 · response
Published 17 June 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Health boards are responsible for ensuring ambulance handovers occur reliably and that receiving hospitals have sufficient capacity.

Verbatim wording from the response
“The Welsh Government’s policy expectation of health boards is that when a patient is conveyed to a hospital by ambulance, care must be handed over to the receiving hospital team as soon as possible, in order of clinical priority and within 15 minutes. Health boards are responsible for ensuring this happens reliably and that there is sufficient available capacity throughout the receiving hospital. This is set out in the Ambulance Patient Handover Guidance.”

Source location
Response from Welsh Government
Page 2 · response
Published 17 June 2025
Open published response
12 May2025
Cornwall and Isles of Scilly
Concerns raised1
1. Insufficient social care provision for patients fit for discharge
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 5
1. Action
  Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.
  Stated by Department of Health and Social CareStated completed
2. Action
  Tackle delayed hospital discharges, beginning with patients staying 21 days beyond their discharge-ready date.
  Stated by Department of Health and Social CareStated planned
3. Action
  Develop local partnership working and increase social care provision to reduce delayed discharges and support timely discharge home.
  Stated by Department of Health and Social CareStated planned
1. Action
  Publish and implement the revised Better Care Fund policy framework prioritising preventative, community-based and integrated health and social care services.
  Stated by Department of Health and Social CareStated completed
2. Action
  Invest £9 billion through the Better Care Fund in integrated health and social care services during 2025/26.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

JAMES FREDERICK SMITH · Prevention of Future Deaths report

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

Report summary

James Frederick Smith, known as Jim, died on 25 June 2024 at Royal Cornwall Hospital Truro after complications during surgery following a fall and fractured hip. The report identified concerns about insufficient social care provision, significant ambulance handover delays, and emergency department crowding, which increased risks to patients and impeded hospital and ambulance capacity.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient social care provision for patients fit for discharge
Wider context from the report
“(1) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital, there being a direct link between inadequate social care provision and ambulance delays. ”
Source location
JAMES FREDERICK SMITH · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the Urgent and Emergency Care Plan for 2025/26 to improve ambulance response and handover, emergency department performance, and delayed discharge.

Verbatim wording from the response
“But we know that we need to start making progress immediately. On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times:”

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Tackle delayed hospital discharges, beginning with patients staying 21 days beyond their discharge-ready date.

Verbatim wording from the response
“• tackling the delays in patients waiting to be discharged, starting with those staying 21 days over their discharge-ready-date.”

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

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop local partnership working and increase social care provision to reduce delayed discharges and support timely discharge home.

Verbatim wording from the response
“We recognise, then, that more needs to be done to develop local partnership working, increase social care provision and tackle delayed discharges to ensure that patients do not remain in hospital when they are well enough to go home.”

Source location
Response from DHSC
Page 3 · response
Published 21 May 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish and implement the revised Better Care Fund policy framework prioritising preventative, community-based and integrated health and social care services.

Verbatim wording from the response
“On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.”

Source location
Response from DHSC
Page 3 · response
Published 21 May 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Invest £9 billion through the Better Care Fund in integrated health and social care services during 2025/26.

Verbatim wording from the response
“On 31 January 2025, the Government published a revised policy framework for the Better Care Fund (BCF), which took effect on 1 April 2025. Through the BCF, £9 billion are invested in integrated health and social care services in 2025-26, including those to tackle delayed discharges and ensure a timely transition for patients into social care. The objectives of the BCF have been reassessed to put a focus on prioritising preventative care such as early intervention services and community-based support to help people stay healthy and independent and increase patient flow through hospital. The BCF also seeks to bring care closer to home by delivering integrated care in local settings, including people’s homes, to support older adults and those with more complex needs.”

Source location
Response from DHSC
Page 3 · response
Published 21 May 2025
Open published response
9 Apr2025
Manchester South
Concerns raised1
1. Lack of suitable non-acute or community provision for medically optimised 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.
Actions described in response 1
1. Action
  Publish the revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.
  Stated by Department of Health and Social CareStated completed
Respondent positions 1
1. Position
  The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.
  Stated by Care Quality CommissionRedirects responsibility
AI-generated summary

Bernard Lyon · Prevention of Future Deaths report

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

Report summary

Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of suitable non-acute or community provision for medically optimised patients
Wider context from the report
“7. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient has waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available. ”
Source location
Bernard Lyon · Prevention of Future Deaths report
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
Publish the revised Better Care Fund policy framework and commit approximately £9 billion for 2025–26 discharge-related activity.

Verbatim wording from the response
“More broadly, this government is committed to tackling delayed discharges through the Better Care Fund (BCF), and its revised policy framework, published on 31 January 2025. For 2025-26, approximately £9 billion is committed to the BCF. This includes around £3.3 billion provided to local authorities and £5.6 billion to integrated care boards, both of which”

Source location
Response from Department of Health and Social Care
Page 5 · response
Published 16 April 2025
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Secretary of State may be better placed to address hospital bed demand and delayed discharges because the issue involves complex competing budgetary demands.

Verbatim wording from the response
“We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect”

Source location
Response from CQC
Page 6 · response
Published 16 April 2025
Open published response
3 Apr2025
Cornwall and Isles of Scilly
Concerns raised1
1. Insufficient social care provision for patients fit for discharge
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 3
1. Action
  Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Andrew Waters · Prevention of Future Deaths report

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

Report summary

Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient social care provision for patients fit for discharge
Wider context from the report
“(3) Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital. ”
Source location
Andrew Waters · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen NHS and social care partnerships to tackle delayed discharges, reduce hospital stays and free beds.

Verbatim wording from the response
“Turning to the issue of delayed patient discharges, the government is tackling delayed discharges to reduce hospital stays and free up beds by strengthening NHS and social care partnerships.”

Source location
Response from DHSC
Page 2 · response
Published 11 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Ask local systems to implement six neighbourhood-health components, including measures to reduce hospital discharge delays.

Verbatim wording from the response
“In January 2025, we set out priorities for the NHS and local authorities on how to move to a neighbourhood health service that delivers more care at home or closer to home. We are asking local systems to systematically implement six core components of neighbourhood health, which will help people stay healthy and independent for longer and reduce unnecessary time spent in hospital, including tackling hospital discharge delays.”

Source location
Response from DHSC
Page 2 · response
Published 11 April 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the new £9 billion Better Care Fund policy framework establishing joint NHS and local-authority accountability for reducing discharge delays.

Verbatim wording from the response
“In January 2025, we also published a new policy framework for the £9 billion Better Care Fund. Under the new framework, the NHS and local authorities have clear accountability for setting and achieving joint goals that include reducing discharge delays.”

Source location
Response from DHSC
Page 2 · response
Published 11 April 2025
Open published response
19 Feb2025
Manchester South
Concerns raised1
1. Delays in discharging medically ready patients awaiting care packages or care home places
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

Kenneth James CLAYTON · Prevention of Future Deaths report

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

Report summary

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

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in discharging medically ready patients awaiting care packages or care home places
Wider context from the report
“3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge. ”
Source location
Kenneth James CLAYTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
31 Jan2025
Liverpool and the Wirral
Concerns raised1
1. Backlog of patients fit for discharge awaiting social care packages
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.
  Stated by Department of Health and Social CareStated planned
2. Action
  Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.
  Stated by NHS EnglandStated in progress
1. Action
  Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.
  Stated by NHS EnglandStated in progress
2. Action
  Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.
  Stated by NHS EnglandStated completed
3. Action
  Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.
  Stated by NHS EnglandStated planned
AI-generated summary

Nicola Emma OWENS · Prevention of Future Deaths report

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

Report summary

Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Backlog of patients fit for discharge awaiting social care packages
Wider context from the report
“The delay in an ambulance attending patients due to the unavailability of ambulances. This delay being significantly contributed to by the handover delays in hospitals. A significant factor contributing to the handover delays in hospitals being the backlog of patients who are fit for discharge but awaiting social care packages. Overall, this entails a lack of staff and room for those patients who are brought in via ambulance thus requiring ambulance crews to remain on hospital premises reducing their ability to attend seriously ill patients. ”
Source location
Nicola Emma OWENS · Prevention of Future Deaths report
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
Develop NHS and social care local partnerships to reduce delayed discharges and ensure hospital departments are no longer blocked by patients awaiting discharge.

Verbatim wording from the response
“Regarding the concern raised about delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged.”

Source location
Response from DHSC
Page 2 · response
Published 31 January 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reform the Better Care Fund so pooled NHS and local-authority funding supports reductions in emergency admissions, delayed discharges and care-home admissions.

Verbatim wording from the response
“We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings.”

Source location
Response from DHSC
Page 2 · response
Published 31 January 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement plans to improve ambulance handovers, response times and urgent and emergency care flow.

Verbatim wording from the response
“NHS England recognises the significant pressure on all NHS services, including ambulance services, and has been prioritising improvements to Category 2 response times and urgent and emergency care (UEC) services. NHS England also recognises that in order to support improved patient flow, there is the need to improve ambulance capacity through growing the workforce, reducing handover delays, speeding up discharges from hospital and expanding new services in the community.”

Source location
Response from NHS England
Page 1 · response
Published 31 January 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Strengthen use of Discharge Ready Date data in operational decision-making to identify delays and support timely discharge.

Verbatim wording from the response
“NHS England recognises that delayed discharges have a significant impact on hospital flow, capacity and ambulance handovers. In order to address this, NHS England is strengthening the use of Discharge Ready Date (DRD) data in order to gain a clearer understanding of discharge delays and their key contributing factors.”

Source location
Response from NHS England
Page 2 · response
Published 31 January 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Publish the 2025/26 Better Care Fund policy framework and planning requirements to support coordinated health and social care discharge plans.

Verbatim wording from the response
“NHS England has also published the 2025/26 Better Care Fund (BCF) policy framework and planning requirements, working alongside the Department of Health and Social Care (DHSC) and Ministry of Housing, Communities and Local Government. The BCF framework supports local systems to jointly agree plans across health and care, including supporting the flow of patients through UEC.”

Source location
Response from NHS England
Page 2 · response
Published 31 January 2025
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with local areas and health, social care and local government partners to improve timely hospital discharge and maximise discharge-funding impact.

Verbatim wording from the response
“NHS England will be working with local areas to support them to maximise the impact of this investment over the coming year, by providing additional or enhanced support to those areas which face particular challenges, and working with partners in local government and social care including Local Government Associations, Directors of Social Services, and Care and Health Improvement advisors to support local systems to improve timely discharge of patients.”

Source location
Response from NHS England
Page 2 · response
Published 31 January 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient social care provision for onward discharge support

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 appropriate community care packages or alternative placements for medically fit patients

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.19

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

Concerns raised1

Delays in arranging timely appropriate community care packages or alternative placements for medically fit patients

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.19

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 2

Actions described in response 19

Respondent positions 1

Actions described in response 19

Respondent positions 1