Recurring concern

Insufficient hospital theatre capacity for timely surgery

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First reported 4 Aug 2022•Latest report 10 Dec 2024

Definition

What this concern includes

Includes shortages or inadequate availability of hospital operating-theatre capacity that delay or threaten timely surgery, including the anchor's shortage of theatre capacity and the separate report's lack of theatre capacity.

Not included

  • Excludes delays caused solely by surgical decision-making, referral, staffing competence or patient preparation when theatre capacity is not deficient.
  • Excludes general hospital, bed or critical-care capacity shortages unless they directly limit operating-theatre capacity for surgery.
  • Excludes failures limited to out-of-hours theatre access, which is covered by the narrower existing concern where applicable.
  • Excludes elective-surgery waiting-time concerns where no theatre-capacity deficiency is identified.
  • Excludes the underlying surgical condition or outcome when no continuing theatre-capacity problem is asserted.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2022–2024

First to latest report issue date

Stated actions
0

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
NHS England1

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. Leicester City and South Leicestershire

    AI-generated summary

    Karen Pamela DACK · 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

    Karen Pamela Dack had worsening bowel stricture and obstruction, and planned surgery was delayed or cancelled on several occasions. Her bowel subsequently perforated, she developed sepsis and died despite further operations. The principal concern was the repeated cancellation of surgery because of limited theatre availability and the risk that similar delays could lead to further deaths.

    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 sufficient theatre capacity to accommodate emergency and elective surgical demand

    Wider context from the report

    “That this lady’s surgery was cancelled at the last minute on three separate occasions due to lack of theatre availability. I heard from the Deputy Clinical Director at Leicester Royal Infirmary that there has been a review of how patients are prioritised and whether they are effectively using their emergency theatre capacity. He said that ‘the obvious problem with emergencies is they are unpredictable, there are times when the emergency list only requires one theatre and there are times when there are so many cases on the emergency list that we need to cancel elective cases in order to accommodate them and SOPs are in place around this.’ He went on to say that there were no imminent plans for theatre expansion at the University Hospitals of Leicester (UHL) and that the categorisation and access to emergency theatres are probably as good as they can get with the currently available resources. I am concerned that whilst UHL is doing its utmost to deal with this problem the fact is that regardless of how patients are categorised there are still the same number of theatres available and that this issue will happen again, and further deaths may occur. ”

    Source location

    Karen Pamela DACK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    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.

    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 theatre capacity

    Wider context from the report

    “2. The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs Harrop’s case that was not achieved due to a lack of theatre capacity. The impact of the delay on her overall physiological reserves was significant ”

    Source location

    Maureen Harrop · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Margaret Ena Warwick · Prevention of Future Deaths report

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

    Report summary

    Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.

    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

    Shortage of theatre capacity causing delays to surgery

    Wider context from the report

    “2. Even after the assessment the Inquest heard evidence that there was a further delay due to a shortage of theatre capacity at the Trust. ”

    Source location

    Margaret Ena Warwick · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026