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.

6 Jul2023
North Wales (East and Central)
Concerns raised1
1. Lack of adequate social care placements or community care for patients medically fit for hospital 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.

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

Emlyn Victor Roberts · Prevention of Future Deaths report

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

Report summary

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

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 adequate social care placements or community care for patients medically fit for hospital discharge
Wider context from the report
“Whilst there was no direct evidence at the inquest to establish whether or not the outcome may have been different if Mr Roberts had received earlier medical care and attention, the delay in the attendance of the ambulance is significant and unacceptable. It is recognised that the reasons for such delay are multifactorial and both I and my Assistant Coroners have issued multiple previous reports for the prevention of future deaths expressing similar concerns. One of my earliest such reports expressing concern regarding ambulance response times, was in relation to a death in March 2013 and yet more than ten years later this problem has become significantly worse rather than better. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medically fit for discharge from hospitals but without adequate placements / care in the community). I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. winter pressures) or with a view to finding longer term solutions. ”
Source location
Emlyn Victor Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jun2023
North Wales (East and Central)
Concerns raised1
1. Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Jean Frickel · Prevention of Future Deaths report

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

Report summary

Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient social care capacity causing hospital patient-flow and ambulance offload delays
Wider context from the report
“There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following:- 1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and 3. Extent of Strategic plan of action / improvement plan to address the above issues. ”
Source location
Jean Frickel · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Jun2023
North Wales (East and Central)
Concerns raised1
1. Inadequate social care placements or community care for patients medically 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.

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

Leonard Charles Harmsworth · 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

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

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 social care placements or community care for patients medically fit for discharge
Wider context from the report
“Following the fall at home on 7ᵗʰ June 2022 WAST were contacted at 05:23. An ambulance arrived 17 hours 22 minutes later. On arrival at Ysbyty Glan Clwyd Leonard Harmsworth was handed in the ambulance for 12 hours 4 minutes before being handed over to nursing staff. Whilst the time it took for the ambulance to arrive to Mr Harmsworth’s home and the time it took for Mr Harmsworth to be handed over to nursing staff at hospital did not cause or contribute to Mr Harmsworth’s death, the delays experienced are significant. It is understood that the matter of ambulance delays is not solely a matter for WAST hence this report being sent to those organisations involved in its impact across the Health Board area (to include the provision of social care where patients are medical fit for discharge from hospitals but without adequate placements / care in the community). I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients and handover at hospitals. I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. ”
Source location
Leonard Charles Harmsworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jan2023
Norfolk
Concerns raised1
1. Failure to discharge medically fit patients when suitable community beds are unavailable
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 2
1. Action
  Invest an additional £1 billion through the Discharge Fund to support timely hospital discharge.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Ensure every acute hospital has access to a care transfer hub for complex discharges.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Lyn Mary BRIND · 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

Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.

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 discharge medically fit patients when suitable community beds are unavailable
Wider context from the report
“6) Evidence was heard that there are regularly too many patients in the Emergency Department and so ambulances cannot safely transport patients into the Emergency Department. The EEAST is working with the Hospital (along with other hospitals in the area) to find ways to deal with this problem and methods are in place to try to alleviate the consequences of these delays. 7) However, it was heard that this is a much wider and more complex problem, in that the Hospital is unable to discharge patients who are medically fit to be discharged and they remain occupying much needed beds. This in turn means patients cannot be moved from the Emergency Department into the hospital wards, and patients remain waiting in ambulances. This in turn causes delays in ambulances being returned to normal duty and being able to attend to emergencies in the community. 8) Evidence was heard that at the time of Mrs Brind's death, approximately 7 ambulances were waiting to transfer patients into the Emergency Department, Queen Elizabeth Hospital. At the time of the inquest, this had risen to 17 ambulances commonly waiting to transfer patients from the ambulance into the Emergency Department. 7) Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community ”
Source location
Lyn Mary BRIND · 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 an additional £1 billion through the Discharge Fund to support timely 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 24 January 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
Ensure every acute hospital has access to a care transfer hub for complex discharges.

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 24 January 2023
Open published response
30 Sep2020
Manchester South
Concerns raised1
1. Delays in putting care packages in place for medically optimised patients
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 4
1. Action
  Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.
  Stated by Department of Health and Social CareStated completed
2. Action
  Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
1. Action
  Review community-based capacity to ensure discharge pathways have the correct types of capacity.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Joseph Michael Cheetham · Prevention of Future Deaths report

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

Report summary

Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.

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 putting care packages in place for medically optimised patients
Wider context from the report
“2. The inquest heard that he was medically optimised, and he had lost weight in hospital whilst awaiting a care package to be put in place. One was still not in place by 24th December and it was likely to be at least another 2-3 weeks before one was in place. To avoid further deconditioning and weight loss in an acute setting whilst awaiting a care package his family took on caring for him at home to facilitate a discharge. ”
Source location
Joseph Michael Cheetham · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Make £1.3 billion available and confirm £588 million to support enhanced hospital-discharge arrangements over winter.

Verbatim wording from the response
“This year we made £1.3billion funding available via the NHS to support the hospital discharge process in March. As part of the £3.6billion funding for winter, an extra £588million was confirmed to continue enhanced discharge arrangements over winter and maintain the safe and timely discharge of patients from hospital.”

Source location
2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 23 November 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.

Verbatim wording from the response
“As part of the initial COVID 19 response, Greater Manchester localities worked to rapidly develop updated Discharge to Assess Pathway Guidance, which were formally approved in late April and have now been adopted across all localities within Greater Manchester. The purpose of the guidance is to improve the flow of all patients being discharged from acute care and to help ensure patients’ needs are assessed in the home or usual place of residence – not in the hospital. If it is not”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 2 · response
Published 23 November 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Create additional community discharge capacity, including reablement support, domiciliary care and community beds.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 3 · response
Published 23 November 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review community-based capacity to ensure discharge pathways have the correct types of capacity.

Verbatim wording from the response
“The guidance is fully aligned with national policy and guidance and there has been significant additional community-based capacity created to support this. The additional capacity includes: reablement support, domiciliary care and community beds. Further work is underway to review community-based capacity to support discharges to ensure the correct types of capacity. There has since been a significant reduction in delayed transfers of care across GM from approximately 5% to less than 1%.”

Source location
2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
Page 3 · response
Published 23 November 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS providers and local partners, including social services, are responsible for timely discharge planning and post-discharge care.

Verbatim wording from the response
“It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. NHS providers are expected to begin planning for a person’s discharge at the point of admission, which should include practical arrangements, care requirements and where the person is being discharged to. The hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.”

Source location
2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
Page 3 · response
Published 23 November 2020
Open published response
30 Jul2020
Manchester South
Concerns raised1
1. Delays in discharge via Adult Social Care
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 2
1. Action
  Maintain cross-system work to improve hospital discharge.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
Respondent positions 1
1. Position
  The local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.
  Stated by NHS Greater Manchester Integrated Care BoardDisputes the concern
AI-generated summary

Reginald Collins · 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

Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and nationally.

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 discharge via Adult Social Care
Wider context from the report
“1. The inquest heard that Mr Collins could have been discharged from 19th September when he was medically optimised. However he remained in an acute hospital setting until his death on 22nd October because of the challenges of finding a suitable EMI placement for him. 2. The inquest heard that an EMI placement would have met his needs in a way that an acute hospital setting could not. 3. The inquest was told that the delay was due in large part to a lack of suitable complex EMI beds both locally and nationally. 4. The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust. ”
Source location
Reginald Collins · 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
Maintain cross-system work to improve hospital discharge.

Verbatim wording from the response
“As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.”

Source location
2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate the Greater Manchester Discharge Pathway and Discharge to Assess system.

Verbatim wording from the response
“As some additional information, as part of the work of the Greater Manchester Adult Social Care Transformation Programme led by the GMHSCP, there is a significant amount of work taking place around market shaping and development and in particular around new and improved models of care and support for people with complex needs. We recognise this is an area which needs improving nationally. We are also working closely across the system on hospital discharge and now have a GM Discharge Pathway and good Discharge to Assess (D2A) system in place.”

Source location
2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The local authority had potential provision and appears to have offered it, disputing that discharge was delayed solely by a lack of suitable placement.

Verbatim wording from the response
“sight of all the relevant information. The Local Authority did have potential provision and it appears did actually offer this. Can we suggest that contact is made with them for further information and clarification on these points. The DASS is more than happy to liaise accordingly (████████@stockport.gov.uk).”

Source location
2020-0146-Response-from-Greater-Manchester-Combined-Authority_Redacted.pdf
Page 2 · response
Published 1 October 2020
Open published response
27 Apr2020
Manchester South
Concerns raised1
1. Delays in arranging suitable community care packages for discharge
This report raised 5 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
  Make £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.
  Stated by Department of Health and Social CareStated completed
2. Action
  Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.
  Stated by Manchester University NHS Foundation TrustStated completed
3. Action
  Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.
  Stated by Manchester University NHS Foundation TrustStated completed
Respondent positions 3
1. Position
  NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.
  Stated by Manchester University NHS Foundation TrustRedirects responsibility
2. Position
  The Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.
  Stated by Manchester University NHS Foundation TrustUnable to act
AI-generated summary

Evelyn Ross · 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

Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

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 suitable community care packages for discharge
Wider context from the report
“2. The inquest was told that whilst Mrs Ross was medically fit for discharge prior to 1st July she had not been discharged because of delays in arranging a suitable care package to support her in the community. ”
Source location
Evelyn Ross · 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 £1.3 billion available through the NHS to fund follow-on care and support patients safely and quickly after hospital discharge during the pandemic.

Verbatim wording from the response
“During the COVID-19 pandemic, we are supporting health and care organisations to ensure we have the capacity to meet the needs of people affected by the virus. The COVID-19 Hospital Discharge Service Requirements published on 19 March are helping to reduce the friction surrounding funding decisions and assessments and focus on getting people out of hospital with the right support as soon as they are medically fit. We have made £1.3 billion funding available via the NHS to help patients who no longer need urgent treatment to get home from hospital safely and quickly. This funding will cover the follow-on care costs for adults in social care, and people in need of additional support, when they are out of hospital and back in their homes, community or care settings, during the pandemic.”

Source location
2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 5 June 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Operate the adult discharge policy through integrated discharge support, multidisciplinary discharge reviews, timely referrals, and documented communication to reduce avoidable delays.

Verbatim wording from the response
“In respect of adult patients such as Mrs Ross, the Trust adheres to a comprehensive local ‘Discharge Policy for Adult Inpatients (excluding Children and Maternity)’, implemented May 2019, a copy of which is enclosed (Appendix 1). At the Trust’s WTWA site this policy is overseen by the Integrated Discharge team. The policy is applicable to all Trust staff who are involved in the assessment, planning and monitoring of patient discharges. It also applies to staff from other health/social care organisations involved in the discharge”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 3 · response
Published 5 June 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide Patient Flow Coordinator and Hospital Discharge Service support for complex discharge planning and identification of patients’ community support needs.

Verbatim wording from the response
“As stated above, a Patient Flow Coordinator role has been developed and successfully appointed to Ward 6 at Trafford General Hospital. In addition, the Hospital Discharge Service is available and responsible for supporting wards in the discharge process of patients, and their input is routinely sought for instance in respect of patients who require special considerations or who may have complex support needs on discharge. The discharge service will assist the ward staff to plan and identify the supporting needs of the patient for discharge.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 4 · response
Published 5 June 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS organisations and local partners, including social services, are responsible for timely discharge and ongoing care arrangements.

Verbatim wording from the response
“It is the responsibility of the NHS and its local partners, including social service departments, to ensure that no patient remains in a hospital bed for longer than clinically necessary and that any ongoing care and support can begin promptly. Discharge arrangements from hospital should start before a patient is ready for discharge and the hospital should involve local social services at the earliest opportunity to plan post-discharge care and avoid delays.”

Source location
2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 5 June 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Discharge arrangements depend on In-reach, Local Authority, Social Care and other bodies undertaking assessments and providing community support.

Verbatim wording from the response
“In line with usual practice in secondary care, patient discharges from hospital are in some cases dependent upon In-reach Psychiatric Liaison Services such as RAID, and/or actions by other bodies such as Local Authorities; for instance assessments in respect of any ongoing package of care required in the community, as well as other bodies in the Social Care sector. It is the Trust’s responsibility to undertake such liaison where applicable to ensure arrangements are in place so that the Trust can effect a safe patient discharge to the community. Given the Trust’s dependence on other parties in respect of this, delays can occur, and this is unfortunately an NHS-wide issue not unique to our Trust. Safe discharge requires teamwork across many people and organisations.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 3 · response
Published 5 June 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust’s ability to progress discharge was limited because In-reach, Social Care and other bodies controlled necessary reviews and placement arrangements.

Verbatim wording from the response
“centre placement was declined by the Local Authority; in order for the clinical team to progress her discharge, as I am sure you will appreciate, there was a limitation on further actions the Trust was able to take to address this issue, due to its dependence on actions by In-reach, Social Care and other bodies.”

Source location
2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
Page 5 · response
Published 5 June 2020
Open published response
28 Nov2017
Staffordshire South
Concerns raised1
1. Failure to move medically fit patients from hospital into suitable social placements
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

Edna Marina Collett · 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

Edna Marina Collett was admitted to hospital on 10 March 2017 and remained there until her death on 19 May 2017. The report identified delays in arranging a suitable community care package, meaning she stayed in hospital for more than two months despite being fit for discharge, and raised concerns about improving the system for moving patients on from hospital.

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 move medically fit patients from hospital into suitable social placements
Wider context from the report
“Mrs Collett was in hospital for more than 2 months. For the great majority of that time she did not need to be in hospital and the reason for her being there was that a suitable social placement could not be found for her. You will be well aware of the pressure on hospital beds. Although it may to some extent be out of your control I wonder if you could please look at the existing system to see if there can be improvements in moving patients on from hospital when they are fit to go. ”
Source location
Edna Marina Collett · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of adequate social care placements or community care for patients medically fit for hospital discharge

Concerns raised1

Insufficient social care capacity causing hospital patient-flow and ambulance offload delays

Concerns raised1

Inadequate social care placements or community care for patients medically fit for discharge

Concerns raised1

Failure to discharge medically fit patients when suitable community beds are unavailable

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

Delays in putting care packages in place for medically optimised 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.4

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 discharge via Adult Social Care

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

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 suitable community care packages for discharge

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to move medically fit patients from hospital into suitable social placements

Actions described in response 2

Actions described in response 4

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 3

Respondent positions 3