27 Jun 2025 Brenda Fisher · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Risk of death from patients remaining for lengthy periods in areas not designed or intended for observations and care View source
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Department of Health and Social Care
Publish the Urgent and Emergency Care Plan for 2025/26 to tackle corridor care and reduce prolonged A&E waits.
View source
Department of Health and Social Care
Provide almost £450 million of capital investment, including funding for Same Day Emergency Care and Urgent Treatment Centres.
View source
Department of Health and Social Care
Eliminate corridor care by improving patient flow.
View source
Department of Health and Social Care
Provide clear pathways and appropriate waiting environments for people attending hospital with urgent needs.
View source
Department of Health and Social Care
Separate urgent from emergency care so patients are treated in the most appropriate setting.
View source
Department of Health and Social Care
Expand access to urgent care services at home and in the community through the Neighbourhood Health model.
View source See 3 more actions
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AI-generated summary
Brenda Fisher · 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
Brenda Fisher died at Stepping Hill Hospital on 16 January 2025 following complications from wounds sustained in a minor accident at home, with her death contributed to by rhabdomyolysis. The court heard that during her final hospital attendance she remained in the Emergency Department’s Rapid Assessment and Triage Corridor for at least 23 hours before a bed was found. The concern was the residual and inherent risk of death when patients remain for lengthy periods in areas not designed for observations and care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Risk of death from patients remaining for lengthy periods in areas not designed or intended for observations and care
Wider context from the report “The court heard evidence that on her final attendance to hospital, Mrs Fisher was cared for in the Emergency Department’s ‘Rapid Assessment and Triage’ Corridor for at least 23 hours before a bed was found for her.
Whilst the Trust has undertaken a number of steps locally to mitigate the risks associated with this practice, I am concerned that there remains a residual and inherent risk of death arising from patients remaining for lengthy periods in areas not designed or intended for undertaking observations and providing care .
” Source location Brenda Fisher · Prevention of Future Deaths report
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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 Publish the Urgent and Emergency Care Plan for 2025/26 to tackle corridor care and reduce prolonged A&E waits.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
Open published response
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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 Provide almost £450 million of capital investment, including funding for Same Day Emergency Care and Urgent Treatment Centres.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
Open published response
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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 Eliminate corridor care by improving patient flow.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
Open published response
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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 Provide clear pathways and appropriate waiting environments for people attending hospital with urgent needs.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
Open published response
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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 Separate urgent from emergency care so patients are treated in the most appropriate setting.
Verbatim wording from the response “In June 2025, we published the Urgent and Emergency Care Plan for 2025/26. The Plan sets out the steps we are taking to tackle corridor care and reduce 12-hour waits in A&E Department’s, including a commitment to eliminate corridor care by improving patient flow. The plan also provides almost £450 million of capital investment including for Same Day Emergency Care and Urgent Treatment Centres. We will provide clear pathways and the right waiting environment when people do need to come to a hospital site with an urgent need. We will take a significant step to separate urgent from emergency care, so that people are treated in the most appropriate setting.” Source location Response from Department of Health and Social Care
Open published response
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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 Expand access to urgent care services at home and in the community through the Neighbourhood Health model.
Verbatim wording from the response “In July 2025, we published the Ten Year Health Plan to create a new model of care, fit for the future. A key focus of our approach will be to expand access to urgent care services at home and in the community as part of our new Neighbourhood Health model. This will improve the experience and care that people receive, rather than having to go to hospital unnecessarily. This will reduce demand in ED’s, meaning that they are liberated to focus on providing the best, most cutting-edge and most productive care for those who most need it.” Source location Response from Department of Health and Social Care
Open published response
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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 is best placed to respond on specific local actions addressing the concerns about prolonged waits, corridor care and operational pressures.
Verbatim wording from the response “The report raises concerns regarding prolonged A&E waits, corridor care and operational pressures faced by Stockport NHS Foundation Trust. I understand that you have also sent a copy of your report directly to the trust who is best placed to respond on the specific actions undertaken locally in response to the concerns you raise. However, in preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.” Source location Response from Department of Health and Social Care
Open published response
1 Nov 2024 Phyllis TROMANS · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of pressure area care for patients positioned on trolleys in the Emergency Department View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Phyllis TROMANS · 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
Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of pressure area care for patients positioned on trolleys in the Emergency Department
Wider context from the report “1. It is likely that Mrs Tromans' tissue damage started during her period in the Emergency Department. On admission, her Waterlow score indicated a high risk of pressure sores. That score was underestimated and the correct score would have indicated a very high risk. She spent almost 18 hours in ED, during which time she was positioned on a trolley without pressure area care.
” Source location Phyllis TROMANS · Prevention of Future Deaths report
Open source report
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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 Deliver targeted Emergency Department training on pressure-ulcer assessment, reporting, skin inspection and repositioning.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
Open published response
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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 Introduce pressure-relieving trolley mattresses and heel-offloading pillows for Emergency Department patients.
Verbatim wording from the response “In response to this, several measures are being taken to prevent future occurrences. Due to the increasing demand on the ED, which has led to patients spending longer than desirable periods in the department, the Tissue Viability team has collaborated with ED Matrons to implement a project aimed at reducing pressure ulcers in the ED. This includes:” Source location Response from University Hospitals Birmingham
Open published response
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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 Audit Emergency Department trolley mattresses and establish a trolley-audit programme.
Verbatim wording from the response “Furthermore, skin champions have been introduced in the ED, with staff undergoing comprehensive training. The department is also working on auditing trolley mattresses to ensure they provide effective pressure reduction, with plans for a trolley audit program in place.” Source location Response from University Hospitals Birmingham
Open published response
26 Apr 2024 Ellen Mercer · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 1
Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Frimley Park Hospital National Institute for Health and Care Excellence NHS England Royal College of Emergency Medicine Royal College of Physicians
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Frimley Park Hospital
Revise the VTE Policy to require assessment after more than 12 hours in the Emergency Department and clarify prophylaxis timescales, exclusions and responsible specialties.
View source
Frimley Park Hospital
Work with the Electronic Patient Record team to add an EPIC prompt when the 12-hour Emergency Department threshold is reached.
View source
Frimley Park Hospital
Update the Data Quality Improvement Plan to assess effectiveness and inform further steps to embed revised VTE practice.
View source
Frimley Park Hospital
Establish a working group to amend the policy and plan rollout, with fortnightly meetings and progress reporting to VTE committees.
View source
Royal College of Emergency Medicine
Issue guidance clarifying that admitting specialty teams are responsible for VTE risk assessments once they assume clinical responsibility in the emergency department.
View source
Royal College of Physicians
Produce a Safety Alert for Physicians addressing delayed admission and prophylactic treatment risks.
View source
National Institute for Health and Care Excellence
Ask the prioritisation board to consider whether guidance should be developed on VTE risk assessment for emergency department patients before admission.
View source See 4 more actions
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AI-generated summary
Ellen Mercer · 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
Ellen Mercer attended Wexham Park Hospital by ambulance in the early hours of 9 February 2023 after deterioration associated with her mental health, nitrous oxide use, leg injuries and reduced mobility. She died in the emergency department approximately 24 hours after arriving; a post-mortem examination identified bilateral pulmonary artery thromboembolus and deep vein thrombosis. The substantive concerns relate to the absence of a formal VTE risk assessment and uncertainty in hospital policies about when the 24-hour period for such an assessment begins, particularly for patients waiting in emergency departments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of current policies to require VTE risk assessment for emergency department patients during prolonged waits
Wider context from the report “1. Patients are unfortunately waiting increasingly longer times in emergency departments – not just in waiting areas, but also after being seen by clinical staff and waiting for admission to a ward or discharge from the hospital. During this time, current policies do not require VTE risk assessment.
2. The policy for this trust suggests that the 24 hour period (during which VTE risk assessment must take place) starts only when a patient is “admitted” to hospital, i.e. when a decision is taken to admit them to a ward – which could be many hours after they have originally attended the emergency department.
3. The policy as currently drafted implies that VTE risk assessment is essentially not relevant for emergency department patients.
4. If current policies require VTE risk assessment to take place within 24 hours, the point at which that 24 hour period starts is not sufficiently clear and does not take long waits in emergency departments into account. I am concerned that policies may need to reflect the current reality on the ground.
5. I suspect that this issue may be a national one.
” Source location Ellen Mercer · Prevention of Future Deaths report
Open source report
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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 Revise the VTE Policy to require assessment after more than 12 hours in the Emergency Department and clarify prophylaxis timescales, exclusions and responsible specialties.
Verbatim wording from the response “At the meeting the clinicians agreed in principle that patients attending the ED who have been present (for whatever reason) for 12 hours or more should be subject to a VTE risk assessment. It was acknowledged that the finer detail of the Trust’s revised policy would need careful consideration and all were particularly mindful of the impact of adding to workloads of ED staff in the absence of additional resource.” Source location Response from Firmley Health NHS Foundation Trust
Open published response
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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 Work with the Electronic Patient Record team to add an EPIC prompt when the 12-hour Emergency Department threshold is reached.
Verbatim wording from the response “• Work with the Electronic Patient Record team to make changes to the Trust’s electronic record keeping system, EPIC, so that a prompt is generated at the relevant time; and” Source location Response from Firmley Health NHS Foundation Trust
Open published response
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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 Update the Data Quality Improvement Plan to assess effectiveness and inform further steps to embed revised VTE practice.
Verbatim wording from the response “In due course the Trust will also need to update the Data Quality Improvement Plan in order to assess the effectiveness of the changes and inform consideration as to whether any further steps are needed to ensure the revised practice is embedded successfully across the Trust. The committees that will oversee progress will primarily be the VTE committee who meet every other month and also report into Patient Safety Steering Group (PSSG) quarterly. Care Governance Committee and quality assurance committees have oversight of the VTE committee’s work and PSSG’s reviews of VTE performance.” Source location Response from Firmley Health NHS Foundation Trust
Open published response
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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 Establish a working group to amend the policy and plan rollout, with fortnightly meetings and progress reporting to VTE committees.
Verbatim wording from the response “In order to progress the above steps, the Trust has assembled a working group who will have responsibility for the amendments to the policy and the plan for rollout. The intention is for the group to meet fortnightly and for a representative to feedback to the afore mentioned VTE committees as to the group’s progress.” Source location Response from Firmley Health NHS Foundation Trust
Open published response
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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 Issue guidance clarifying that admitting specialty teams are responsible for VTE risk assessments once they assume clinical responsibility in the emergency department.
Verbatim wording from the response “We note from your Regulation 28: Report to Prevent Future Deaths notice that you identify the delay in a risk assessment for the prevention (as opposed to treatment) of venous thromboembolism (VTE) being a concern and that the timing of the risk assessment may be subject to variation. As a medical royal college we have issued guidance on clinical responsibility for patients who are located in the emergency department but who have been seen by and are under the clinical care of a team other than the emergency medicine team. This guidance states “Once a patient in the ED is seen by a specialty team, then that patient becomes the responsibility of the specialty team” [3]. This guidance was issued to ensure that emergency department doctors are able to prioritise the assessment and treatment of newly arrived patients in a timely fashion.” Source location Response from Royal College of Emergency Medicine
Open published response
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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 Produce a Safety Alert for Physicians addressing delayed admission and prophylactic treatment risks.
Verbatim wording from the response “In light of this case we will produce a Safety Alert for Physicians, and also liaise with NHSE England National Clinical Director for Urgent and Emergency Care, National Clinical Director for Patient Safety and The Society for Acute Medicine.” Source location Response from Royal College of Physicians
Open published response
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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 Ask the prioritisation board to consider whether guidance should be developed on VTE risk assessment for emergency department patients before admission.
Verbatim wording from the response “The scope of the guideline does not cover people in the emergency department prior to admission. We have therefore not made any recommendations that cover the circumstances described in your report.” Source location Response from National Institute for Health and Care Excellence
Open published response
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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 VTE risk assessment remains the admitting specialty team’s responsibility, including when patients remain in the emergency department.
Verbatim wording from the response “We do not think it is likely to be effective to require ED staff, who are already experiencing issues with their capacity, to undertake a specific risk assessment for VTE. This is supported by the Royal College of Emergency Medicine (RCEM), who we note in their response to you, have stated that ‘it is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process’ and that this is the ‘role of the admitting specialty doctors, even when a patient is still in the ED’. The RCEM has issued clinical guidance on the clinical responsibility for patients who are located in the ED but who have been seen and are under the clinical care of another team. The guidance states that ‘Once a patient in the ED is seen by a specialty team, then the patient becomes the responsibility of the speciality team’.” Source location Response from NHS England
Open published response
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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 NICE, rather than NHS England, is responsible for changing national VTE guidance on when assessments should occur.
Verbatim wording from the response “The National Institute for Health and Care Excellence (NICE), who I note you have also addressed your Report to, are responsible for the relevant clinical guidelines [NG89] for VTE risk assessment.” Source location Response from NHS England
Open published response
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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 Emergency medicine doctors are not responsible for VTE risk assessments specifically relating to the hospital admission process.
Verbatim wording from the response “It is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process; this is the role of the admitting specialty doctors, even when the patient is still in the ED. We would however expect emergency department doctors to undertake a VTE risk assessment for those patients who are being admitted for a prolonged period under the care of the ED team to a clinical area such as a Clinical Decision Unit or Observation Ward run solely by the emergency department.” Source location Response from Royal College of Emergency Medicine
Open published response
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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 Admitting specialty doctors are responsible for VTE risk assessments relating to hospital admission, including while patients remain in the emergency department.
Verbatim wording from the response “It is not the role of emergency medicine doctors to be undertaking risk assessments that specifically relate to the hospital admission process; this is the role of the admitting specialty doctors, even when the patient is still in the ED. We would however expect emergency department doctors to undertake a VTE risk assessment for those patients who are being admitted for a prolonged period under the care of the ED team to a clinical area such as a Clinical Decision Unit or Observation Ward run solely by the emergency department.” Source location Response from Royal College of Emergency Medicine
Open published response
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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 Timing venous thromboembolism interventions from admission is inappropriate amid admission delays; timings should instead run from attendance or specialty referral.
Verbatim wording from the response “In the current context of delays for admission we do not believe that timing interventions from admission is appropriate, and these should be modified as timings from attendance or speciality referral. Each hospital should have a local policy that agrees on clinical responsibility for patients waiting for admission in Emergency Departments.” Source location Response from Royal College of Physicians
Open published response
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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 guideline does not cover people in emergency departments before admission, so it makes no recommendations for that circumstance.
Verbatim wording from the response “The scope of the guideline does not cover people in the emergency department prior to admission. We have therefore not made any recommendations that cover the circumstances described in your report.” Source location Response from National Institute for Health and Care Excellence
Open published response
14 Sep 2022 Maureen Harrop · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Lack of support for patients during prolonged emergency department waits View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Maureen Harrop · 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
Maureen Harrop, a care home resident, suffered an accidental fall resulting in a fracture to the neck of her femur. She experienced prolonged waits in the Emergency Department and for surgery, which was delayed because of limited bed and theatre capacity. She later developed a urinary tract infection, deteriorated, and died from urosepsis; the report raised concerns about the impact of these delays on her condition.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of support for patients during prolonged emergency department waits
Wider context from the report “1. The inquest heard that Mrs Harrop had a prolonged stay in the ED at the Hospital because of lack of bed capacity. The Inquest heard that given her age and the fracture the impact of the prolonged wait on her was significant particularly in light of the lack of support available to her ;
” Source location Maureen Harrop · Prevention of Future Deaths report
Open source report
2 Jun 2021 GEOFFREY WILLIAM HILL · Prevention of Future Deaths report Black Country
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Concerns raised 1
Failure to undertake falls risk assessments for vulnerable and elderly A&E patients during prolonged stays View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
GEOFFREY WILLIAM HILL · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Geoffrey William Hill, aged 82, was admitted to hospital with Covid-19, reduced mobility and general illness, and fell from a trolley bed in the emergency department, sustaining a head injury. He later became unresponsive and died in hospital from a traumatic subdural haemorrhage. Concerns included the absence of a falls risk assessment, trolley rail assessment, advanced observations, mental test and therapy assessment, and the broader lack of national guidance for falls prevention in emergency departments.
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× 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 undertake falls risk assessments for vulnerable and elderly A&E patients during prolonged stays
Wider context from the report “(7) I am concerned that vulnerable and elderly patients in A & E can spend long periods without any falls risk assessments being undertaken placing them at risk .
” Source location GEOFFREY WILLIAM HILL · Prevention of Future Deaths report
Open source report
Concerns raised 1
Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Gillian McKinlay · 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
Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear allocation of overall clinical responsibility for patients remaining in the Accident and Emergency Department
Wider context from the report “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care .
2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams.
3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy.
4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken:
a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate;
b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred;
c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken;
d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect;
e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked;
f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect.
” Source location Gillian McKinlay · Prevention of Future Deaths report
Open source report
25 Feb 2020 Beryl Holland · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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AI-generated summary
Beryl Holland · 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
Beryl Holland sustained a fractured neck of femur after a fall at the care home where she resided, underwent surgery at Stepping Hill Hospital, continued to decline post-operatively, and died there on 7 July 2019. The concerns related to her prolonged stay in the Emergency Department while awaiting a ward bed, her vulnerability to pressure ulcers, and the absence of national guidance for managing pressure-ulcer risks in Emergency Department settings.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of Trust policies to recognise and respond appropriately to pressure-ulcer risk during prolonged Emergency Department stays
Wider context from the report “The inquest heard that Beryl Holland was in the Emergency Department of the Acute Hospital for a significant period of time before ultimately been transferred to a ward. This was due to awaiting a suitable bed. She was vulnerable and at high risk of developing pressure ulcers. The trust in question had identified gaps in its processes and taken steps to reduce the risk of pressure ulcers developing/worsening in the Emergency Department. The inquest was told that there is no national guidance relating to the management of/reducing the risks of pressure ulcers developing in an Emergency Department setting. As a result, Trusts will develop their own policies, which may not always recognise and react appropriately to the level of risk faced by those at risk of pressure ulcers particularly where there are prolonged periods of time in the Emergency Department .
” Source location Beryl Holland · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance, local NHS policies and the emergency department safety checklist provide relevant arrangements for preventing and managing pressure ulcers.
Verbatim wording from the response “I am aware that the National Institute for Health and Care Excellence (NICE) has advised you in its response that a clinical guideline is available on the Prevention and Management of Pressure Sores (CG179)¹ and that this guideline provides specific recommendations to clinicians in relation to patients receiving care in emergency department settings if they have a risk factor. It is the view of NICE that this guideline provides relevant guidance.” Source location 2020-0037-Response-from-the-Department-for-Health-and-Social-Care
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.