17 Apr 2024 Mr Timothy Charles Clayton · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure to protect properly considered discharge planning from bed-space pressure 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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Mr Timothy Charles Clayton · 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
Mr Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.
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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 to protect properly considered discharge planning from bed-space pressure
Wider context from the report “3. The pressure to vacate bed spaces impacted on clinicians’ ability to prepare a properly considered discharge plan and led to rushed uninformed decision making.
” Source location Mr Timothy Charles Clayton · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional acute bed capacity, supported by capital investment, to improve hospital flow and reduce discharge pressure.
Verbatim wording from the response “The delivery plan for recovering urgent and emergency care services committed to providing the NHS with additional bed capacity to improve hospital flow and performance. The target of 5,000 additional core general and acute beds, against previously planned levels, was met and consistently exceeded in January 2024, supported by £250 million for 30 capital schemes across the country. 2024/25 operational planning guidance sets out an ask for systems to maintain their levels of acute core general and acute beds in 2024/25, and to expand their bedded and non-bedded intermediate care capacity, through the additional £400 million distributed via the Better Care Fund (BCF), to support improvements in hospital discharge and enable step-up care in the community.” Source location Response from NHS England
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PFD Monitor interpretation Review, update and approve the discharge policy to identify vulnerable patients, involve families and clarify safe-discharge responsibilities and escalation processes.
Verbatim wording from the response “The Root Cause Analysis undertaken following this incident identified the fact that Mr Clayton was a vulnerable adult and so a complex discharge pathway should have been triggered as required within the Trust’s discharge policy. As a result of this investigation, the principles of effective discharge processes were reviewed, safe check lists embedded into practice and clinical practice reviewed. Subsequent to the Inquest the Hospital Discharge and Criteria to Reside Policy (ESTH/POL/64521) has been reviewed, updated and approved and shared with staff in the organisation. This policy provides clarity on the identification of vulnerable patients for discharge and outlines the responsibilities of patients, family and carers to be included in the discharge planning. The policy encourages families to raise concerns and, where concerns are raised, supports how these are managed.” Source location Response from St George's, Epsom and St Helier
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PFD Monitor interpretation Strengthen discharge escalation pathways and communicate safe-discharge expectations through senior-leadership presentations and staff communications.
Verbatim wording from the response “As a result of the Inquest and the concerns raised, the Trust has revised the discharge policy to ensures that the processes to gather the information required, the responsibilities of clinicians and the escalation processes for safe, timely and appropriate discharge of patients are clear. Staff have been encouraged to escalate to their senior managers when they have concerns regarding discharge through the Topic of the Week. The Site Chief Medical Officer and Site Chief Nursing Officer has presented this at key senior leadership meetings including the Clinical Leads meeting, Divisional Senior Leadership Team meeting and Divisional Medical Directors meetings. Escalation processes have been strengthened to ensure that there is a clear pathway for concerns for clinical and clinical operational teams within working hours and out of hours.” Source location Response from St George's, Epsom and St Helier
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Concerns raised 1
Unavailability of hospital beds for informal admission View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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Department of Health and Social Care
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Nicolas Gerasimidis · Prevention of Future Deaths report
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Report summary
Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.
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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 Unavailability of hospital beds for informal admission
Wider context from the report “The Trust’s Patient Safety Review identified the following concerns:
- When Mr Gerasimidis was referred by his GP to the community mental health team, he was screened out, in part, due to challenging staffing issues;
- No care coordinator was appointed owing to a shortage of staff;
- The Trust had and continues to have vacancies at consultant level;
- The family was wrongly advised the Trust was not commissioned to treat OCD;
- The family was not informed of a nearest relative’s right under the Mental Health Act to request a case review by an AMHP;
- Psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention had a waiting list of one year;
- In May 2023, when it was felt Mr Gerasimidis required an informal admission into hospital, no beds were available .
The difficulties with staff recruitment and bed availability are long term problems in the Cornwall coroner area. The Patient Safety Review suggests Cornwall has fewer beds for its population than other areas. It is the persistent or recurring nature of these concerns that leads me to believe action should be taken.
” Source location Nicolas Gerasimidis · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The ICB considers its commissioned mental health bed capacity appropriate because it matches the national median per 100,000 population.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
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PFD Monitor interpretation The ICB relies on alternative solutions to mitigate the impact of closed mental health beds.
Verbatim wording from the response “The ICB are aware of these bed closures and have been assured by CFT that the impact had been mitigated with alternative solutions” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Closed acute and rehabilitation beds cannot be reinstated because of environmental issues being challenged through the provider’s contract.
Verbatim wording from the response “The response from NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB) is focused on your concern around the availability of beds and the transformation work underway more locally. The ICB reports that their commissioning of mental health beds is in line with the national median number of beds per 100,000 population which is 9.45. has advised that its contract with Cornwall Foundation Partnership Trust (CFT) specifies 54 acute mental health beds, however, data shows that there were 47 operational at the date of Mr Gerasimidis' sad death. This remains the situation today. The CFT has 7 closed Acute beds and 6 closed Rehab beds. These beds cannot be reinstated due to environmental issues which are being challenged through CFT Private Finance Initiative contract at the highest level, with the CFT Chief Executive.” Source location Response from DHSC
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23 Nov 2023 Philip Laurence Justin MALONE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Philip Laurence Justin MALONE · Prevention of Future Deaths report
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Report summary
Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.
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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 Unsafe exceptional process for creating psychiatric bed capacity through discharge of current patients
Wider context from the report “1. Despite recognising Mr Malone needed to be admitted to a psychiatric hospital in June 2023 but there was no bed capacity, BSMHFT’ RCA report identified no remedial action.
2. The Patient Safety Manager ████████ gave evidence that the lack of psychiatric bed capacity remains an ongoing problem and has not been resolved, and there is a genuine risk of the same problem with another patient in the future.
3. ████████ added there was an exceptional process, which required a considered decision at a high level, to make a bed available through identifying someone currently occupying a bed space to be discharged . In my view, this process is unsatisfactory as it creates a different set of risks around the patient being discharged , and amplifies the chronic shortage of beds.
4. There was reference to two preceding Regulation 28 Reports to Prevent Future Deaths (both available publicly on the judiciary website) that focussed on the chronic lack of mental health resources in Birmingham and Solihull. In relation to the specific issue of a lack of psychiatric bed capacity, in the case of Peter Fleming (no bed was available in August 2022) BSMHFT’s response (September 2023) referred to their response in the earlier case of Leroy Hamilton (no bed was available in December 2021). This response (April 2023) stated more resources had been obtained and a collaborative plan had been implemented with NHS Birmingham and Solihull Integrated Care Board.
The issue of adequately funding psychiatric beds is a local and national issue. Locally, BSMHFT require their commissioners to provide the necessary funding.
My principal concern is that the above dates indicate available psychiatric bed capacity in Birmingham and Solihull remains inadequate. Whilst some action may have been taken it is insufficient to resolve the problem. It follows there is a genuine risk of future deaths directly connected to a shortage of psychiatric bed spaces in Birmingham and Solihull unless further action is taken.
” Source location Philip Laurence Justin MALONE · Prevention of Future Deaths report
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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 local authorities to improve inpatient social-care support and enable faster, safer discharges.
Verbatim wording from the response “The Trust is working with our local authorities to improve the social care support to patients on our inpatient wards with an aim to provide speedier and safer discharges and thus create more capacity within our bed stock (See appendix 1)” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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How this respondent action was interpreted
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PFD Monitor interpretation Operate a clinical oversight group with acute wards to support appropriate discharges and escalate delays caused by non-clinical issues.
Verbatim wording from the response “A clinical oversight group (COG) now meets regularly with all acute wards to support clinically appropriate discharges and enable escalation of discharge delays that occur as a result of non-clinical issues (appendix 2).” Source location Response from Birmingham and Solihull Mental Health NHS Foundation Trust
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1 Nov 2021 Neil Peter Bastock · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 1
Bed-availability pressure influencing section rescission decisions View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds and York Partnership NHS Foundation Trust
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Neil Peter Bastock · Prevention of Future Deaths report
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Report summary
Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.
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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 Bed-availability pressure influencing section rescission decisions
Wider context from the report “1. The decision to rescind the section on 17.09.2020 was made:
a. by a responsible clinician who had been in this role for only two weeks.
b. his family were not involved in the decision at all and only became aware of it after it had been made.
c. no formalised assessment of his mental capacity was made prior to the decisions.
d. his care plan had not been updated.
e. the pressure on bed availability in the Newsam Centre may have influenced the decision .
” Source location Neil Peter Bastock · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Rescinding detention did not discharge the patient or affect bed availability; discharge decisions are clinically based and not driven by resource pressures.
Verbatim wording from the response “e. The pressure on bed availability in the Newsam Centre may have influenced the decision.” Source location 2021-0365-Response-from-Leeds-and-York-Partnership-NHS-Foundation-Trust_Published
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13 Jul 2021 Abiodun Adisa ORITOGUN · Prevention of Future Deaths report Inner South London
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Concerns raised 1
Failure to ensure that ITU admission criteria are not driven by capacity constraints View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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Abiodun Adisa ORITOGUN · Prevention of Future Deaths report
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Report summary
Mr Abiodun Adisa Oritogun was admitted with severe acute pancreatitis, deteriorated on the ward, and died after collapsing while self-discharging; the inquest concluded that he died from complications of pancreatitis and ileus. Concerns included inadequate monitoring and escalation after his condition worsened, and uncertainty about whether patients with severe pancreatitis received an appropriate level of care and ITU referral.
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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 to ensure that ITU admission criteria are not driven by capacity constraints
Wider context from the report “The coroner found that there were two concerns about medical care, namely
1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning.
2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year.
Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that
a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward
b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care .
” Source location Abiodun Adisa ORITOGUN · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply nationally derived critical-care admission criteria, with urgent intensive-care review within 60 minutes and admission or ward-management advice.
Verbatim wording from the response “Our criteria for admission to critical care (ITU or HDU) are the same as those adopted nationally. These criteria are derived from “Guidelines on admission to and discharge from Intensive Care and High Dependency Units” published by the Department of Health in March 1996; these guidelines are still applicable and current. The type of patients who require ITU care are unstable and have a requirement for multiple organ monitoring and/or support. Patients admitted to HDU are those requiring single organ support, or those who need observation and monitoring that cannot be safely provided on a general ward.” Source location Response from Lewisham and Greenwich NHS
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the SELACCN and SPRINT support agreement to facilitate transfer to the nearest available critical-care bed when local capacity is unavailable.
Verbatim wording from the response “As a secondary response, where an urgent bed is unlikely to become available within our own hospital critical care unit, we have a support agreement in place with the South-East London Adult Critical Care Network (SELACCN) and the Specialist Retrieval and Intensive Care Transfer service (SPRINT). The SPRINT team includes a critical care consultant, nurse and paramedic who can provide ITU and HDU level care in an ambulance, and operates its base from our own NHS Trust.” Source location Response from Lewisham and Greenwich NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Admission decisions are not refused or driven by critical-care bed shortages when lower-level care is clinically inappropriate.
Verbatim wording from the response “Critical care beds in both ITU and HDU are a finite resource. There can be times when demand outstrips available capacity. This is recognised nationally, and each NHS Trust is required to have plans available to deal with such capacity constraints.” Source location Response from Lewisham and Greenwich NHS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Critical-care capacity constraints are addressed through immediate specialist support, safe interim care, and transfer arrangements to available local critical-care beds.
Verbatim wording from the response “In the immediate response, we provide a critical care doctor (or airway trained anaesthetist) and a CCOT nurse to care for such patients wherever they may be, whether in the general wards, operating theatres, emergency department or elsewhere in the hospital.” Source location Response from Lewisham and Greenwich NHS
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30 Sep 2020 Joseph Michael Cheetham · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of acute hospital bed capacity View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 10
Department of Health and Social Care
Continue rolling out Urgent Treatment Centres to provide a consistent urgent-care service.
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Department of Health and Social Care
Continue Same Day Emergency Care initiatives to reduce non-elective hospital admissions.
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Department of Health and Social Care
Maintain Nightingale Hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
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Department of Health and Social Care
Expand NHS 111 to provide urgent-care advice and direct patients to appropriate services more quickly.
View source
NHS Greater Manchester Integrated Care Board
Implement agreed principles requiring direct specialty acceptance, specialty assessment of stable patients, and expanded Same Day Emergency Care across Greater Manchester.
View source
NHS Greater Manchester Integrated Care Board
Implement NHS 111 First so patients are directed to call 111 before attending an Emergency Department.
View source
NHS Greater Manchester Integrated Care Board
Implement pre-Emergency Department triage and streaming to direct patients to the most appropriate service.
View source
NHS Greater Manchester Integrated Care Board
Adopt and implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, discharge medication, testing, PPE and next-day follow-up processes.
View source
NHS Greater Manchester Integrated Care Board
Create additional community discharge capacity, including reablement support, domiciliary care and community beds.
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NHS Greater Manchester Integrated Care Board
Review community-based capacity to ensure discharge pathways have the correct types of capacity.
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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.
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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 acute hospital bed capacity
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
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Urgent Treatment Centres to provide a consistent urgent-care service.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue Same Day Emergency Care initiatives to reduce non-elective hospital admissions.
Verbatim wording from the response “In 2019/20, this involved continued work to tackle both the increases in demand in urgent and emergency care and to ensure patients receive the quality of care they need and expect in a timely and safe manner. For example, the continued roll out of Urgent Treatment Centres, offering a consistent service to patients and introducing the ability to book appointments through NHS 111, as well as initiatives such as Same Day Emergency Care, to reduce non-elective admissions to hospital.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain Nightingale Hospitals, their surge capacity and NHS use of independent-sector hospital capacity.
Verbatim wording from the response “This year, we have provided an extra £3billion to alleviate the particular challenges brought by the Covid-19 pandemic ahead of winter and are maintaining the Nightingale Hospitals and their surge capacity, as well as the NHS’s use of independent sector hospital capacity.” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand NHS 111 to provide urgent-care advice and direct patients to appropriate services more quickly.
Verbatim wording from the response “Other elements of the NHS winter plan for 2020/21 include the expansion of NHS 111 to support patients who need urgent care advice and direct them to the right service more quickly, rather than waiting in A&E².” Source location 2020-0189-Response-from-Dept.-of-Health-and-Social-Care_Redacted.pdf
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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
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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
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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
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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 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
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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
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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
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15 May 2019 Mildred CLARK · Prevention of Future Deaths report North East Kent
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Concerns raised 1
Pressure on staff to avoid hospital admission 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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Mildred CLARK · 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
Mildred CLARK died in hospital on 17 December 2017 following infection and failure of a bypass graft, haemorrhage, and inadequate blood supply to the leg. The inquest found that delay in diagnosing the infection and haematoma limited the available medical intervention. A separate concern was raised about a paramedic being instructed by telephone to attempt hernia reduction despite not being trained to do so, and about possible pressure on staff to avoid hospital admission during winter pressure.
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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 Pressure on staff to avoid hospital admission
Wider context from the report “Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.
(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure
” Source location Mildred CLARK · Prevention of Future Deaths report
Open source report
5 Apr 2017 Ronald William Bennett · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Lack of hospital bed availability delaying patient admission 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
South East Coast Ambulance Service NHS Foundation Trust University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
University Hospitals Sussex NHS Foundation Trust
Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.
View source
University Hospitals Sussex NHS Foundation Trust
Review service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.
View source
University Hospitals Sussex NHS Foundation Trust
Implement the SAFER care bundle to improve patient flow and support earlier discharge.
View source
University Hospitals Sussex NHS Foundation Trust
Expand Newhaven Downs Community Hospital to create additional discharge capacity.
View source
University Hospitals Sussex NHS Foundation Trust
Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.
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AI-generated summary
Ronald William Bennett · 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
Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his death.
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 hospital bed availability delaying patient admission
Wider context from the report “(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day).
(2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate.
(3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds .
(4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death.
(5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH.
” Source location Ronald William Bennett · 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 Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.
Verbatim wording from the response “(3) We now have a £31m capital scheme in development to expand the emergency floor, including an expanded Urgent Care Centre at the Royal Sussex County Hospital, more GP input to the Emergency Department and an ambulatory emergency care facility in advance of next winter.” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-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 Review service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-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 Implement the SAFER care bundle to improve patient flow and support earlier discharge.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-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 Expand Newhaven Downs Community Hospital to create additional discharge capacity.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-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 Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.
Verbatim wording from the response “(4) The Trust’s Clinical Transformation Programme includes the following measures:” Source location 2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
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 Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.
Verbatim wording from the response “Although I cannot give you assurance that this complex and multi-factorial problem is fixed, I am confident that the matter is now being given sufficient priority by our acute, community and primary care partners. Its impact on our services is significant, and we are doing all we reasonably can to ensure improvement is sustained.” Source location 2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.