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

Distinct published reports

Individual concerns
30

A report can raise multiple concerns

Date range
2017–2026

First to latest report issue date

Stated actions
97

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Inner West London

    AI-generated summary

    Junior George Powell · 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

    Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of suitable community social care delaying discharge of patients ready to leave hospital

    Wider context from the report

    “That delay in discharge for patients ready to be discharged due to lack of suitable social care in the community is causing congestion in the hospital admission process, delaying medical assessment and thus diagnosis of conditions that need urgent treatment and increasing the likelihood of death for such patients. ”

    Source location

    Junior George Powell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Cornwall and Isles of Scilly

    AI-generated summary

    Kevin George Woods · Prevention of Future Deaths report

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

    Report summary

    Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.

    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

    Inadequate community hospital provision for discharges

    Wider context from the report

    “2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays. ”

    Source location

    Kevin George Woods · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate social care provision for discharges

    Wider context from the report

    “2) There is a direct connection between the risk of ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED, shortage of beds in acute wards, and handover delays. This creates a risk of future systemic failures causing ambulance delays. ”

    Source location

    Kevin George Woods · 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

    Develop local NHS and social-care partnerships and support arrangements to reduce delayed discharges and enable patients to return home sooner.

    Verbatim wording from the response

    “This government is working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 8 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure every acute hospital has access to a care transfer hub for complex discharges.

    Verbatim wording from the response

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

    Source location

    Response from DHSC
    Page 2 · response
    Published 8 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work directly with health and social-care partners in integrated care systems experiencing the greatest discharge delays to drive improvements.

    Verbatim wording from the response

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

    Source location

    Response from DHSC
    Page 2 · response
    Published 8 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Healthcare providers are responsible for identifying and mitigating risks within their services through their own patient-safety processes.

    Verbatim wording from the response

    “The responsibility for identifying and mitigating risks within healthcare services sits with the provider of those services. Each provider of NHS services will have their own internal processes and structures for the identification, examination, management and improvement of patient safety risks. The Care Quality Commission (CQC) is responsible for monitoring the quality and safety of the care provided by NHS Trusts through the regulation of the Trust’s regulated activities. The CQC carries out inspections and produces reports setting out their findings.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 8 October 2024

    Open published response
  3. Manchester South

    AI-generated summary

    George Neville Coulthard · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in identifying suitable care home placements

    Wider context from the report

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

    Source location

    George Neville Coulthard · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

    Response from GMIC
    Page 4 · response
    Published 24 September 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.

    Verbatim wording from the response

    “As part of our processes, we are currently conducting a further assessment (under our new Single Assessment Framework) to review all the shortfalls identified at the last inspection and consider if there has been sufficient improvement. If we do not believe the registered provider has appropriately addressed the breaches of regulation to the extent”

    Source location

    Response from CQC
    Page 4 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update statutory hospital-discharge guidance to support safe, coordinated transfers and continuity of care.

    Verbatim wording from the response

    “This funding is pooled via the Better Care Fund, which requires integrated care boards (ICBs) and local authorities to make joint plans and pool budgets for the purposes of providing more joined-up and effective care. Every acute hospital has access to a care transfer hub. These hubs bring together professionals from the NHS and social care to manage discharges for people with more complex needs and who need extra support. Statutory guidance on hospital discharge (updated in January 2024) sets out how local authorities and NHS bodies can ensure that people are discharged safely from hospital to the most appropriate place and continue to receive the care and support they need, taking into account the legal duties in the Health and Care Act 2022.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Care home placement shortages and hospital discharge delays fall outside the regulator’s remit.

    Verbatim wording from the response

    “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 3 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Secretary of State and Greater Manchester Integrated Care are considered better placed to address care placement shortages and discharge delays.

    Verbatim wording from the response

    “We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Secretary of State and Greater Manchester Integrated Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

    Source location

    Response from CQC
    Page 3 · response
    Published 24 September 2024

    Open published response
  4. Cornwall and Isles of Scilly

    AI-generated summary

    DENNIS RICHARD HARRY · 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

    Dennis Richard Harry died at Royal Cornwall Hospital on 10 January 2023 from heart disease and Covid-19 infection following an 18-hour-and-50-minute ambulance delay, including delays in response and hospital handover. The report identified systemic concerns about inadequate social care, community hospital provision and primary healthcare support contributing to delayed discharges, ambulance delays and emergency department crowding. It also identified no single organisation with responsibility for ensuring sufficient social care provision or overseeing patient safety risks from ambulance delays.

    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

    Inadequate community hospital provision for discharges

    Wider context from the report

    “1) There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays. This creates a risk of future systemic failures causing excessive ambulance delays. ”

    Source location

    DENNIS RICHARD HARRY · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate social care provision for discharges

    Wider context from the report

    “1) There is a direct connection between the risk of excessive ambulance delays and inadequate social care provision, community hospital provision and primary healthcare support for discharges in Cornwall. This is because the inadequacies in these services lead to delayed discharges causing crowding in ED and handover delays. This creates a risk of future systemic failures causing excessive ambulance delays. ”

    Source location

    DENNIS RICHARD HARRY · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Increase productivity across acute and non-acute bedded and non-bedded services.

    Verbatim wording from the response

    “In the short-term, a range of action is being taken by the NHS this year to improve urgent and emergency care performance, including by maintaining capacity gains in acute hospital beds and ambulance hours on the road achieved in 2023-24, increasing the productivity of acute and non-acute services across bedded and non-bedded capacity, and directing patients to more appropriate services in the community where these can better meet their needs.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop local NHS and social-care partnerships and coordinate support to reduce delayed discharges and enable timely returns home.

    Verbatim wording from the response

    “This government is also working to improve hospital flow to make sure people do not spend longer than necessary in hospital and reduce delayed discharges. We will tackle delayed discharges by developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure every acute hospital has access to a care transfer hub for complex discharges.

    Verbatim wording from the response

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

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 September 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work directly with health and social-care partners in integrated care systems experiencing the greatest discharge delays to drive improvements.

    Verbatim wording from the response

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

    Source location

    Response from DHSC
    Page 2 · response
    Published 24 September 2024

    Open published response
  5. Wiltshire and Swindon

    AI-generated summary

    Richard Carpenter · 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

    Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of appropriate community care packages for patients fit for discharge

    Wider context from the report

    “The reason I am submitting this Regulation 28 Report is that I heard evidence when I put the question to ████████ as to whether or not the Trust is hitting its targets in relation to ambulance response, and I was told that the Trust was not meeting those targets consistently in a way comparing to pre-pandemic times. When I drilled down further as to where problems lay, again the issue of patients in hospitals taking up beds arose in circumstances whereby the patient was physically fit for discharge but they were not able to be discharged due to the lack of appropriate care packages in the community. This issue has arisen in other Regulation 28 Reports that I have written to you recently and I am concerned as regards the lack of availability of sufficient free beds in hospital due to bed blocking is still causing significant disruption to ambulance services trying to transfer patients to hospital. Although on this occasion I did not find a causal link between the delay and Richard’s death, I am concerned that delays in ambulances attending patients in the community are likely to increase the risk of death in Cat 2 instances especially that would otherwise be preventable had the patient been got to hospital in a timely fashion. ”

    Source location

    Richard Carpenter · 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

    Invest £1 billion through the Discharge Fund to commission discharge care packages and improve discharge processes.

    Verbatim wording from the response

    “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Launch a £40 million fund for local authorities facing significant urgent and emergency care pressures.

    Verbatim wording from the response

    “£1 billion was invested this year through the Discharge Fund in commissioning packages of care for people being discharged and improving discharge processes. A £40 million fund was also launched in September 2023 for local authorities in areas with the greatest challenges on urgent and emergency care. Local authorities used this funding for social care provision and strengthening admissions avoidance and discharge services over the past winter. The number of people discharged from hospital with packages of health and social care support has increased by 9% from the end of March 2023 to the end of March 2024.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 April 2024

    Open published response
  6. Wiltshire and Swindon

    AI-generated summary

    Margaret Avril Burman · Prevention of Future Deaths report

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

    Report summary

    Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of appropriate community care causing medically fit patients to remain on hospital wards

    Wider context from the report

    “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided. During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls. She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover. As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards. Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death. The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile. I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge. As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures. The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money. The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed. As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play. ”

    Source location

    Margaret Avril Burman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Improve discharge processes and capacity modelling to support appropriate commissioned community care capacity.

    Verbatim wording from the response

    “Your Report also raises a concern around patients medically fit for discharge are remaining in hospital due to a lack of appropriate community care being available. This remains a challenge for the NHS and social care services across England. As a key part of NHS England’s Urgent & Emergency Care recovery, NHS England together with colleagues across the DHSC and the Department for Levelling up, Housing and Communities (DLUHC) are focussed on improving discharge processes and capacity modelling to ensure the right number of commissioned beds/non-bedded care.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 April 2024

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    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake programmes improving admissions avoidance and discharge flow to reduce patients remaining in acute medical beds without criteria to reside.

    Verbatim wording from the response

    “A range of programmes aimed at improving both admissions avoidance and discharge flow is being undertaken to support the reduction in the number of patients in acute medical beds with no criteria to reside. This work is a key priority for the NHS and is being driven through the published NHS Operational Planning Guidance and the Better Care Fund planning process and has associated improvement support available to regions and local systems.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 April 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.

    Verbatim wording from the response

    “I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 29 April 2024

    Open published response
  7. Cornwall and Isles of Scilly

    AI-generated summary

    ROBERT ANDREW PROWSE · Prevention of Future Deaths report

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

    Report summary

    Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.

    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 secure sufficient domiciliary or residential care for medically fit hospital patients

    Wider context from the report

    “6. In other words, the investigations found that there is a direct link between failings in social care provision and ambulance delays. The failings in social care provision were found to have a knock-on effect through healthcare services. It was found that at times hospitals were unable to transfer patients from hospital wards into the community when clinically indicated. This is because of the difficulty in securing sufficient domiciliary or residential care, as and when required. This leads to delayed discharges from hospital of patients deemed medically fit for discharge. 7. Furthermore, it was found that delayed discharge can lead to an increase in rehabilitation and care needs. This is an effect of delayed discharge leading to further impact upon hospital capacity. 8. It was found that the build-up of patients in wards (patients who are medically fit for discharge) means that the hospitals are, at times, unable to transfer patients from the emergency department to hospital wards when clinically indicated. This in turn leads to a build up of patients in emergency departments. ”

    Source location

    ROBERT ANDREW PROWSE · Prevention of Future Deaths report
    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

    Invest an additional £1 billion through the Discharge Fund to support timely and effective hospital discharge.

    Verbatim wording from the response

    “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ensure every acute hospital has access to a care transfer hub supporting complex discharges and early planning.

    Verbatim wording from the response

    “We are also investing an additional £1 billion this year through the Discharge Fund, to support the NHS and local authorities to ensure timely and effective discharge from hospital. This funding follows £600 million last year and £500 million in 2022/23. The NHS and local authorities are using this funding to help provide people with the right care in the right place when they are discharged from hospital. We have also ensured every acute hospital has access to a care transfer hub, bringing together professionals from the NHS and social care to manage discharges for people with more complex needs who need extra support with a view to promoting early planning and timely discharge. These measures are helping improve patient flow through hospitals, reducing delays in patient handovers so ambulances can swiftly get back on the roads.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 April 2024

    Open published response
  8. Cornwall and Isles of Scilly

    AI-generated summary

    KENNETH HEARD · 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 Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.

    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 provision delaying discharge of medically fit patients

    Wider context from the report

    “(7) Notwithstanding these mitigating measures, concern arises from present circumstances, in relation to handover delays across the region covered by SWAST and specifically at the two hospitals most commonly used by patients from Cornwall, Derriford Hospital in Plymouth and Treliske Hospital in Truro. (8) The most recent data available is for August 2023, in which month across the region covered by SWAST the hospitals suffering the longest ambulance delays were Treliske, Derriford and Gloucester. The data indicated that operational resource hours lost due to handover delays in excess of 15 minutes was as follows: 5,107 hours lost at Derriford Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 2:04:36 2,449 hours lost at Treliske Hospital, Average Handover Time per Incident (Hrs:Mins:Sec) 1:01:13 (9) Response times during June, July and August 2023 were heavily impacted by the handover delay pressures. The best response times were delivered on the weeks with the lowest hours lost to handover delays. The data for time lost due to handover delays at Derriford and RCHT in June, July and August 2023 are set out below. Operational Resource Hours Lost to Handover Delays in Excess of 15 Minutes Time Lost in June 2023 Time Lost in July 2023 Time Lost in August 2023 Derriford Hospital 4714:17 3436:41 5107:36 Treliske Hospital 2833:15 2386:23 2449:47 (10) By comparison the court was informed that before the pandemic the average number of hours lost due to handover delays was approximately 4,000 hours per month across the whole of the SWAST region. During 2022 the average number of hours lost due to handover delays was approximately 25,000 hours per month across the whole of SWAST. The worst month of last year was December 2022. The number of hours lost due to handover delays in that month across the whole of SWAST region, was approximately 35,000. (11) The court heard evidence that there are future circumstances creating a concern of a risk to life, namely the seasonal nature of demands on SWAST. The winter months are likely to see an increase in demand for ambulance services and for hospital beds. December 2022 was the most demanding month of last year and featured the longest delays in response and handover. December 2023 is likely to be the most demanding month of this year. (12) The root cause for ambulance delays was found to be the lack of social care provision in Cornwall, whether care packages or beds in care homes. It was acknowledged and accepted by NHS representatives at Inquest that Treliske and Derriford are unable to discharge otherwise medically fit patients due to the lack of social care provision. This means that wards are accommodating patients who would otherwise be discharged. The hospital wards being full beyond capacity, means that emergency departments are unable to move patients out of emergency beds into the wards. This means in turn that the emergency department is full and unable to receive patients from ambulances. This leads to the handover delays, and consequently response delays, documented in the data set out above. ”

    Source location

    KENNETH HEARD · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide £1.6 billion over two years to support timely and effective hospital discharge.

    Verbatim wording from the response

    “I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 29 November 2023

    Open published response
  9. Manchester South

    AI-generated summary

    Terence Davenport · 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

    Terence Davenport, who had severe dementia, was pushed by another resident at Kings Park Nursing Home on 23 May 2022, suffered a fractured neck of femur, and died at Tameside General Hospital on 24 September 2022 after declining following surgery. Concerns included his prolonged stay in an acute hospital because a suitable care placement was unavailable, and inadequate information sharing about the other resident’s aggressive behaviour, which meant risks to staff and residents were not understood.

    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 care and nursing bed capacity causing unsuitable acute hospital placements

    Wider context from the report

    “1. The inquest heard evidence that the acute hospital setting was difficult for Mr Davenport due to his dementia and created risks to his health once he was medically optimised. He had to remain there due to a lack of suitable care/nursing beds. This meant that he was in an unsuitable care setting and that a bed that could have been utilised for an acute patient was not available; ”

    Source location

    Terence Davenport · 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

    Operate the Home Finders Team to facilitate timely, appropriate discharge placements and release acute capacity.

    Verbatim wording from the response

    “Ensuring acute capacity is available in our hospitals is an ongoing and significant challenge across Greater Manchester. In Tameside, there is a Home Finder Team based in the Integrated Urgent Care Team (IUCT) at Tameside Integrated Care Foundation Trust who work with patients and families to facilitate a timely and appropriate discharge for medically optimised patients so acute beds can be made available.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 1 · response
    Published 30 October 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Hold weekly Executive Length of Stay meetings and continuously monitor patients with No Criteria to Reside to identify and remove discharge barriers.

    Verbatim wording from the response

    “2. Tameside locality partners meet weekly in an Executive Length Of Stay meeting to consider any barriers to discharging patients with “No Criteria to Reside” (NCTR) and work together to identify and remove any barriers to appropriate discharge. The number of patients with NCTR are monitored continuously both locally and at GM level to inform understanding of the capacity of the system to meet ongoing needs of the population.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 30 October 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide direct digital support to residential and nursing homes to help residents remain in or return to care settings after discharge.

    Verbatim wording from the response

    “3. Tameside Digital Health Team (based at Tameside ICFT) provide a face to face digital service directly with Residential and Nursing Homes to support residents to remain in the Care Sector with support wherever possible. They will also support in working with Residential and Nursing Homes to support residents in the Home once they have been discharged.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 2 · response
    Published 30 October 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a system-wide workforce and market development mitigation plan to support nursing-care providers’ resilience during winter and the medium term.

    Verbatim wording from the response

    “System-wide market risks across GM have been escalating over the past 9-12 months, with the highest in the nursing care market. Impact on residents and the workforce continues to be minimised by system leaders and providers when nursing homes exit the market either by de-registering/ownership or closure. We anticipate that there will be more closures over the coming months, and that these will continue to be managed locally with as least impact as possible. A system-wide mitigation plan focussing on workforce and market development has been developed to support providers to remain resilient over Winter and into the medium-term.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 3 · response
    Published 30 October 2023

    Open published response
  10. Manchester South

    AI-generated summary

    Thomas Barton · 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

    Thomas Barton was admitted to hospital for a urinary tract infection and remained there while arrangements for additional care at home were organised. He contracted COVID-19 during the delayed discharge, deteriorated with dysphagia and aspiration pneumonia, and was discharged to a nursing home on end-of-life care, where he died. The principal concern was that delays in discharge caused by limited social care availability placed frail elderly patients at increased risk of deconditioning, infection and preventable death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient availability of suitable social care causing delayed hospital discharges

    Wider context from the report

    “The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop an infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. The evidence was that speedier discharges would occur if there was improved availability of social care and that this would improve outcomes for elderly patients and reduce the risk of preventable deaths occurring. ”

    Source location

    Thomas Barton · 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 Hospital Discharge and Community Support Guidance setting out hospital discharge and community support processes.

    Verbatim wording from the response

    “It is our priority to ensure that all patients receive safe and timely discharges from hospital. The Hospital Discharge and Community Support Guidance published by the Department of Health and Social Care, sets out how the discharge process should operate in practice, and how NHS bodies and Local Authorities should work together to plan and implement hospital discharge, recovery and reablement in the community. NHS bodies and local authorities have a statutory duty to cooperate in exercising their”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide and increase the Adult Social Care Discharge Fund to support additional care packages, beds, equipment and social care workforce capacity.

    Verbatim wording from the response

    “We put in place £500million for the 2022/2023 Adult Social Care Discharge Fund and this enabled more people to be discharged from hospital in a timely manner. We have since increased the Fund to £600million for the 23/24 and to £1billion for 24/25. This funding has so far been used to deliver additional care packages and beds, provide equipment to support people in returning home, and boost the social care workforce. Local authorities and NHS integrated care boards have the flexibility to spend their allocations in ways they deem most appropriate for their local area. Funding must be spent on measures which seek to free up the maximum number of hospital beds and reduce bed days lost, for example short-term packages of care, community-based reablement capacity, or building the workforce capacity needed to continue to support care users.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue working with NHS and local authorities to roll out care transfer hubs across the country for complex discharges.

    Verbatim wording from the response

    “In January 2023, NHS England published the Urgent and Emergency Care Recovery Plan. This year, and in line with the commitments in this plan, we continue to work with the NHS and local authorities to roll out care transfer hubs in every part of the country to manage discharges for patients with more complex needs. These hubs bring together professionals from the NHS and local authority to manage discharges for people with more complex needs, who need extra support when being discharged.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Fund home-from-hospital support from voluntary and community organisations alongside independent care providers.

    Verbatim wording from the response

    “Response from NHS GM: Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 3 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Undertake capacity and demand modelling of homecare and care-home markets to inform local market development.

    Verbatim wording from the response

    “NHS GM have recently undertaken capacity and demand modelling of home care and care home markets. Localities are using the detailed modelling and analysis to inform development and shaping of their market, to ensure that it continues to meet the needs of current and future Greater Manchester residents.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 3 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS GM considers commissioned home-from-hospital support and existing care capacity sufficient to support timely hospital discharges.

    Verbatim wording from the response

    “Response from NHS GM: Whilst we appreciate that during the period of time that Mr Barton was in hospital there was increased demand on care at home, we are confident that there is sufficient capacity to support timely discharges from hospital for people to return to their homes. Supported by NHS GM funding, localities have commissioned home from hospital support from voluntary/community organisations in addition to the independent care providers that provide substantive services.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 3 · response
    Published 28 July 2023

    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

    Trafford Council considers existing homecare, residential care and supported-living provision sufficient in those areas, despite identified specialist capacity gaps.

    Verbatim wording from the response

    “As indicated above, there is a reasonable supply of homecare currently.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 28 July 2023

    Open published response
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Data last updated 7 September 2026