Recurring concern

Unsafe operational pressure in emergency departments

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First reported 30 Apr 2019•Latest report 3 Oct 2024

Definition

What this concern includes

Includes failures or hazards within the emergency-department operational process where workload, demand, crowding or time-target pressure directly threatens safe clinical assessment, documentation, escalation or decision-making, including the A&E four-hour deadline pressure and pressure from acute-patient influxes.

Not included

  • Excludes generic staffing, funding or workload concerns without a direct emergency-department patient-safety impact.
  • Excludes failures of a separate named emergency-department process, such as triage, observation, diagnostic investigation or discharge, unless operational pressure is itself identified as the shared unsafe condition.
  • Excludes ambulance-service, police-control-room or non-emergency-department operational pressure.
  • Excludes ordinary performance targets or workload descriptions that do not identify unsafe pressure affecting care.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2019–2024

First to latest report issue date

Stated actions
3

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
Barts Health NHS Trust1
the Shrewsbury and Telford Hospital NHS 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. Manchester South

    AI-generated summary

    John Turner · 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

    John Turner died at Tameside General Hospital on 23 August 2023 from a pulmonary embolism due to a deep vein thrombosis, neither of which had been identified when he attended the Emergency Department three days earlier. The concerns included significant deviation from the Manchester Triage System, a requested D-Dimer test not being undertaken, delayed recording of a senior doctor’s findings, and reduced scope to identify atypical major or life-threatening illness during periods of unremitting demand.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Reduced scope for identifying atypically presenting major or life-threatening illness in Emergency Departments

    Wider context from the report

    “In the present case, the court heard evidence as to significant deviation (which can particularly occur at times of high demand) from the Manchester Triage System which seeks to safely manage patient flow with reference to competing needs. In addition, it was almost 8 hours before the senior doctor who reviewed Mr Turner on 20th August 2023 recorded her findings in the electronic patient record, in all likelihood reflecting competing clinical demands on her time. In the light of the above, I am concerned, as a practical consequence of unremitting demand on this and other Emergency Departments, the scope for identifying major or life-threatening illness which presents atypically is significantly reduced. ”

    Source location

    John Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. East London

    AI-generated summary

    Elvon Paul Randolph Morton · 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

    Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

    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 escalate and mitigate workload pressure affecting patient safety

    Wider context from the report

    “2. Witnesses blamed poor documentation on workload, specifically an influx of acute patients into the resuscitation bays. Despite this, no evidence was presented that any attempt was made to mitigate this pressure by, escalating the matter to the site manager, nor did the on-call ED consultant find it necessary to come in to the unit. These actions tend towards a “coping culture” inconsistent with patient safety. ”

    Source location

    Elvon Paul Randolph Morton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.

    Verbatim wording from the response

    “A specific induction programme has been formulated for the A&E which specifically covers themes such as the mental capacity act, contemporaneous documentation including emergency administered drugs with rationale, sedation and also escalation. The induction programme will be delivered and evidenced retained. A specific presentation relating to the Mental Capacity Act (MCA) its implementation in practice and the wider considerations will be delivered within the teaching programmes for all grades within A&E.”

    Source location

    Response from Barts Health
    Page 2 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Arrange consultant attendance for specified emergency procedures in line with professional guidance.

    Verbatim wording from the response

    “The Trust are supportive of staff that are increasingly managing high numbers of complex and acutely unwell patients. In this case, doctors sought and were provided with advice from a consultant on call. The consultant on call will attend to perform certain procedures (in line with the Royal College of Emergency Medicine guidance). With the benefit of hindsight, consultant presence would have provided support for the trainees.”

    Source location

    Response from Barts Health
    Page 2 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review emergency-department working patterns and consultant cover through a wider discussion.

    Verbatim wording from the response

    “The clinical review group agree that a wider discussion needs to take place to review WXH A&E working patterns and consultant cover, these discussions are complex and will likely take place over the next 12 months in conjunction with other improvement work being undertaken to manage patient flow within the hospital. Risks in relation to ED pressures including overcrowding and resus capacity are reflected on the WXH risk register.”

    Source location

    Response from Barts Health
    Page 3 · response
    Published 14 May 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The primarily local concerns are for Barts Health NHS Foundation Trust to address.

    Verbatim wording from the response

    “In preparing this response, Departmental officials have made enquiries with NHS England. The department is advised that the matters of concern raised are primarily local and for Barts Health NHS Foundation Trust to address, who confirm they are in receipt of this report. The report provides a further opportunity for the Trust to reflect and assure itself that it has acted on all the learnings to be taken from Mr Morton’s death. It is vital that lessons are learnt collectively, and changes are made to reflect where things have gone wrong, which is essential to ensure the NHS provides safe, high-quality care.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 14 May 2024

    Open published response

  3. Shropshire, Telford and Wrekin

    AI-generated summary

    Mark Richard HINTON · 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

    Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.

    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

    Operational pressure from the A&E four-hour deadline

    Wider context from the report

    “(3) Other matters arising. a) A second set of observations should have been made before Mark was discharged. This did not happen. b) The D-Dimer test result was delayed due to a systems error with the CS2500 machine. It is stated that this may have happened intermittently and is then corrected. Had the system error not occurred it is likely that the (8th) result would have been available on screen for the discharging doctor to review. c) Telephone results are not made if the patient is an in-patient in A&E. The Standing Operation Procedure (SOP) in Pathology states “D-Dimer greater than 500ug/l telephone to GP, out-patients and outlying hospitals (excludes SATH in-patients)”. Is a patient waiting assessment in A&E an out-patient or in-patient or some other category? d) Differential diagnosis. Had all the information to the discharging doctor a differential diagnosis of DVT may have been made and recorded. e) A body map had not been completed at any time. f) Oramorph was recorded as having been given but not checked. Also it may the mask symptoms of pain. g) Whilst D-Dimer tests were becoming routine rather than clinically required, Mark had come in with a possible ‘clot’ whether his earlier symptoms had improved or not. h) The absence of documentation made it difficult if not impossible to resolve factual discrepancies between members of staff. i) The impression given by witnesses was that they were under pressure (racing against the clock) to meet the 4 hour deadline in A&E. ”

    Source location

    Mark Richard HINTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026