Elizabeth Jane Brown · Prevention of Future Deaths report

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Issued 12 Mar 2024•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Insufficient qualified and trained immunology staffing
    Part of recurring concern: Insufficient qualified healthcare staffing capacity
  2. Delays in access to specialist immunology clinics
    Part of recurring concern: Excessive waiting times for specialist referrals

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. NHS England

    Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.

  2. NHS England

    Implement reviews of patients waiting for clinically necessary repeat outpatient monitoring appointments to reduce long waits.

  3. NHS England

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

  4. NHS England

    Deliver the Long-Term Workforce Plan through strategic workforce planning and expanded domestic education, training and recruitment.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. NHS England

    Trusts are responsible for ensuring safe staffing levels in the day-to-day operation of their hospitals.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. NHS England

    Follow-up waiting times are normally for local monitoring rather than national NHS England oversight.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient qualified and trained immunology staffing

Wider context from the report

“The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January. Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies. The position was not improving in terms of recruiting to vacant posts the inquest was told ”

Is this part of a recurring concern?

Yes — Insufficient qualified healthcare staffing capacity.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in access to specialist immunology clinics

Wider context from the report

“The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January. Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies. The position was not improving in terms of recruiting to vacant posts the inquest was told ”

Is this part of a recurring concern?

Yes — Excessive waiting times for specialist referrals.

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

Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.

Verbatim wording from the response

“NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.”

Source location

Response from NHS England
Page 2 · response
Published 19 March 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

Implement reviews of patients waiting for clinically necessary repeat outpatient monitoring appointments to reduce long waits.

Verbatim wording from the response

“The issue highlighted in this case appears to relate to follow up waiting times rather than new outpatient waiting times and as such this would normally be for local monitoring. However, the national Outpatient Transformation Team are exploring ways to reduce long waiting times for patients who need monitoring by implementing reviews of those on the waiting list for repeat appointments to which continue to be clinically necessary. This work is planned for 2024/25.”

Source location

Response from NHS England
Page 1 · response
Published 19 March 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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Further Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 19 March 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

Deliver the Long-Term Workforce Plan through strategic workforce planning and expanded domestic education, training and recruitment.

Verbatim wording from the response

“NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.”

Source location

Response from NHS England
Page 2 · response
Published 19 March 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

Trusts are responsible for ensuring safe staffing levels in the day-to-day operation of their hospitals.

Verbatim wording from the response

“These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels at local level in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.”

Source location

Response from NHS England
Page 2 · response
Published 19 March 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

Follow-up waiting times are normally for local monitoring rather than national NHS England oversight.

Verbatim wording from the response

“The issue highlighted in this case appears to relate to follow up waiting times rather than new outpatient waiting times and as such this would normally be for local monitoring. However, the national Outpatient Transformation Team are exploring ways to reduce long waiting times for patients who need monitoring by implementing reviews of those on the waiting list for repeat appointments to which continue to be clinically necessary. This work is planned for 2024/25.”

Source location

Response from NHS England
Page 1 · response
Published 19 March 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026