Recurring concern

Failure to provide suitable accommodation for patients awaiting care

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First reported 19 Sep 2018•Latest report 19 Jan 2026

Definition

What this concern includes

Includes failures to provide, maintain or allocate suitable accommodation for patients who are waiting for assessment, treatment, admission, transfer or onward care, including unsuitable overnight locations and inadequate waiting areas.

Not included

  • Excludes general hospital or mental-health bed shortages unless they directly result in patients awaiting care being accommodated in an unsuitable or inadequate area.
  • Excludes clinical treatment, observation, staffing or documentation failures where patient accommodation is not the unsafe condition.
  • Excludes unsuitable accommodation for family carers, staff or non-patient visitors.
  • Excludes environmental defects unrelated to the suitability or adequacy of accommodation for patients awaiting care.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2018–2026

First to latest report issue date

Stated actions
11

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 Care2
Care Quality Commission1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Health Services Safety Investigations Body1
Maidstone and Tunbridge Wells NHS Trust1
NHS England1
the Dudley Group NHS Foundation Trust1

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. Essex

    AI-generated summary

    Martin Douglas Bryant · 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

    Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.

    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 capacity for suitable waiting accommodation within the MHUCD

    Wider context from the report

    “2. EPUT’s ability to accommodate improvement to where people wait within the MHUCD, particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment. ”

    Source location

    Martin Douglas Bryant · 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

    Require risk assessment for patients waiting for medical review or beds, with escalation when necessary.

    Verbatim wording from the response

    “In order to address the risks associated with waiting in an open reception area, management process has changed to ensure a risk assessment has been undertaken whilst patients await medical review and / or beds are secured for them. There are clear escalation processes in place when patients are waiting for beds.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 26 January 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Keep vulnerable patients in swipe-access assessment rooms when risk assessment indicates reception waiting is unsafe.

    Verbatim wording from the response

    “This risk assessment is used to identify if someone is safe to wait in reception area and if not they will remain in an assessment room (this information was included in the action plan shared with Coroner and process had changed at point of inquest).”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 1 · response
    Published 26 January 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Apply criteria and escalation processes for temporarily closing the MHUCD when safe staffing, capacity, acuity, complexity or triage thresholds are exceeded.

    Verbatim wording from the response

    “The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review MHUCD capacity daily and escalate capacity issues through scheduled locality and senior bed escalation meetings.

    Verbatim wording from the response

    “Capacity of the unit is reviewed and there is the opportunity for escalation at the morning and afternoon MSE Locality Sit rep calls seven days a week. Capacity issues can also be escalated at lunchtime Senior Bed Escalation Huddles, which are held Monday-Friday.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    EPUT is best placed to address concerns about the MHUCD waiting area and accommodation for people awaiting triage, assessment or beds.

    Verbatim wording from the response

    “1. The reliance by Essex Partnership University NHS Foundation Trust (EPUT) that those suffering a mental health crisis will wait in the open reception area of the Mental Health Urgent Care Department (MHUCD), from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 26 January 2026

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing capacity criteria and escalation processes allow the MHUCD to close temporarily and divert patients when safe accommodation is unavailable.

    Verbatim wording from the response

    “The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

    Source location

    Response from Essex Partnership University NHS Foundation Trust
    Page 2 · response
    Published 26 January 2026

    Open published response
  2. Mid Kent and Medway

    AI-generated summary

    KATHERINE MABEL HOGAN · 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

    Katherine Hogan died at Maidstone Hospital on 31 August 2019 after sustaining a severe head injury and major haemorrhage from a high-impact fall from a trolley in the clinical decision unit. The concerns included staff shortages, the use of an unsuitable area for keeping a patient overnight, and an outstanding request for increased staffing that had not been addressed by the Trust.

    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 keep patients in a suitable area overnight

    Wider context from the report

    “(1) Staff shortages contributed to the patient being left the clinical decisions area of the unit on a trolley. This was not an area that was suitable to keep a patient overnight. Staff shortages were reported to those responsible for the hospital. (2) Evidence is that the unit has moved and has been reconfigured, however there remains an outstanding request for increased staffing that has not been addressed by the Trust. ”

    Source location

    KATHERINE MABEL HOGAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update and disseminate the department protocol and admission criteria, including closure of the unit when suitable staffing is unavailable.

    Verbatim wording from the response

    “The patient was left in the CDU on a trolley due to the historical department protocol not being followed. The patient did not meet the admission criteria for the CDU however was still admitted to this area. As a result of this incident, action has been taken to update the department protocol and admission criteria. The updated department protocol and admission criteria has been disseminated to all staff within the department. The updated department protocol now states that the unit must be closed if there is no suitable staff allocated to the unit.”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 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

    Update the CDU standard operating process to define its short-stay purpose, admission and exclusion criteria, discharge planning, and prohibition on placing patients requiring admission there.

    Verbatim wording from the response

    “As the Court have noted, the Clinical Decision Unit (CDU) has been reconfigured. In line with this, the Trust now confirms that a Standard Operating Process (SOP) as regards the CDU has been updated and amended. This SOP sets out the intended use of the CDU. The provisions of this SOP include:”

    Source location

    2020-0243-Response-from-Maidstone-and-Tunbridge-Wells-Redacted.pdf
    Page 2 · response
    Published 24 December 2020

    Open published response
  3. Suffolk

    AI-generated summary

    Piotr Kierzkowski · 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

    Piotr Kierzkowski was found deceased at home on 17 December 2019 after experiencing a mental health crisis and being assessed for admission to a psychiatric unit. No bed was available, so he was sent home with a friend and took his own life before he could return to hospital. The principal concerns were overall bed capacity for people seeking informal admission and arrangements for temporarily housing a patient when a bed is 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

    Insufficient provision to temporarily house patients awaiting informal admission

    Wider context from the report

    “In evidence it was heard that Piotr had not received his ‘depot’ medication for some time and was clearly suffering from a psychotic episode at the time of his assessment at the Accident and Emergency department of the West Suffolk Hospital on the 16th December 2019 Piotr told staff he was not actively suicidal at that point in time, and although the staff were concerned about his presentation, under mental health law least restrictive principles, they did not believe the powers of detention under the Mental Health Act were applicable. That said, it was also clear from the evidence that the mental health personnel who saw Piotr wanted to immediately admit him as an informal patient. It was also clear that when Piotr attended hospital on the 16th December 2019, he too wanted to be immediately admitted as an informal patient. As a result, staff tried to locate a bed for Piotr so he could be admitted as all involved wished. However, it was identified that there were no beds available in Suffolk, or anywhere else in the country at the time. Different options of keeping Piotr in the hospital were explored but none were viable. As such, Piotr was prescribed medication to reduce his immediate anxiety and sent home with a friend, with instructions to return if his symptoms deteriorated. Piotr took his own life the next morning before he could be returned to hospital. Had a bed been available and Piotr had been admitted as he and medical staff had wished on the evening of the 16th December 2019, his death would not have occurred. I am therefore concerned in relation to the overall bed capacity for those patients like Piotr seeking informal admission. In addition, I am concerned about the provisions to temporarily house a patient wishing informal admission in the circumstances that a bed is not immediately available. ”

    Source location

    Piotr Kierzkowski · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Manchester South

    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

    Failure to provide suitable waiting conditions in A and E

    Wider context from the report

    “1. The inquest heard that his GP had sought to have him admitted directly into hospital having identified that he needed to be hospitalised. However, contact with the trust identified that the acute bed shortage meant that this would not be possible, and he would have to go via A and E. On arrival at A and E the volume of those waiting to be seen meant that he waited in cold and draughty areas of the department. Lack of bed capacity in the hospital meant that he spent over 24 hours in the A and E department despite being frail and vulnerable. ”

    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

    Allocate additional capital funding, including £3.611 million for Stepping Hill Hospital’s emergency-department upgrade.

    Verbatim wording from the response

    “NHS Trusts across England, including the Stockport NHS Foundation Trust, will receive a share of £450million additional capital funding to upgrade their facilities ahead of this winter and ensure the NHS is prepared to cope with winter pressures and reduce the risks associated with further outbreaks of Covid-19. Stepping Hill Hospital, Stockport is being allocated £3,611,000 of this funding to upgrade its emergency department.”

    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

    Implement agreed principles requiring direct specialty acceptance, specialty assessment of stable patients, and expanded Same Day Emergency Care across Greater Manchester.

    Verbatim wording from the response

    “As part of the Greater Manchester Urgent Transformation Programme, we have developed and agreed a set of principles for all localities to adopt which will help to prevent a re-occurrence of this. The agreed principles are as follows:”

    Source location

    2020-0189-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redacted.pdf
    Page 1 · 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

    Implement NHS 111 First so patients are directed to call 111 before attending an Emergency Department.

    Verbatim wording from the response

    “• Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department”

    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

    Implement pre-Emergency Department triage and streaming to direct patients to the most appropriate service.

    Verbatim wording from the response

    “• A new pre-Emergency Department triage and streaming system”

    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
  5. Black Country

    AI-generated summary

    Hubert Kelly · 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

    Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.

    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 space or resources for patients awaiting further assessment

    Wider context from the report

    “1. Evidence emerged during the inquest that following triage assessment nursing staff lacked room or resources to allow patients to remain in the ambulance triage area or in a cubicle and consequently patients were left to wait in corridors; 2. There was no meaningful interaction with patients waiting for further assessment including no permanent medically qualified staff in the waiting area; 3. Waiting times at the emergency department were frequently exceeding the four-hour waiting time set nationally, with patients waiting to be seen by clinicians for up to seven hours. ”

    Source location

    Hubert Kelly · 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

    Expand the triage area to increase patient capacity, privacy and dignity.

    Verbatim wording from the response

    “The Trust has implemented a nationally recognised triage tool and has robust audit relating to timeliness and quality of triage. We have also expanded our triage area to increase capacity and privacy and dignity. In times when demand is high we have a way of performing observations on patients quickly.”

    Source location

    Hubert-Kelly-Response
    Page 1 · response
    Published 19 September 2018

    Open published response
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Data last updated 7 September 2026