PFD report

Garth Pretorius · Prevention of Future Deaths report

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Issued 8 May 2026•East Riding and Hull

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Source document

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 raised1

  1. Failure to use a single validated triage system universally in the Emergency Department
    Part of recurring concern: Unreliable operation of the Manchester Triage System
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Address wider emergency-department safety factors, including patient flow, communication, deterioration recognition and timely sepsis management.

    Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2026.
  2. Action

    Complete the expanded Manchester Triage System training, assessment and competency sign-off programme for all triage staff.

    Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Immediate senior clinical assessment is considered an appropriate alternative to formal Manchester Triage System application in operationally feasible circumstances.

    Stated by NHS Humber Health PartnershipExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Failure to use a single validated triage system universally in the Emergency Department

Wider context from the report

“Evidence was heard from the Court’s independent expert that it is unacceptable for two different triage systems to be employed simultaneously in the Emergency Department of Hull Royal Infirmary. Professor Fletchager gave evidence that the Manchester system is validated and internationally accepted, but at material times, another system was used and continues to be used. Some practitioners use the Manchester system whilst others use a different system. Evidence was heard that the use of the Manchester system requires training and there do not appear to be sufficient resources still available for it to be adopted universally at Hull Royal Infirmary. ”

Is this part of a recurring concern?

Yes — Unreliable operation of the Manchester Triage System.

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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

Address wider emergency-department safety factors, including patient flow, communication, deterioration recognition and timely sepsis management.

Verbatim wording from the response

“The Trust has taken, and continues to take, substantive action to ensure the universal, reliable application of the Manchester Triage System, supported by training, governance and audit. In parallel, we are addressing wider systemic factors identified through detailed investigation, including emergency department flow, communication, recognition of deterioration, and the timely management of sepsis.”

Source location

Response from Humber Health Partnership
Page 2 · response
Published 23 July 2026

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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

Complete the expanded Manchester Triage System training, assessment and competency sign-off programme for all triage staff.

Verbatim wording from the response

“Implementation of the Manchester Triage System”

Source location

Response from Humber Health Partnership
Page 1 · response
Published 23 July 2026

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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

Immediate senior clinical assessment is considered an appropriate alternative to formal Manchester Triage System application in operationally feasible circumstances.

Verbatim wording from the response

“Where operationally feasible, the Trust positions senior clinical decision-makers at the front door of the Emergency Department between 08:00 and 00:00.”

Source location

Response from Humber Health Partnership
Page 2 · response
Published 23 July 2026

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