PFD report

Maureen Brenda Batchelor · Prevention of Future Deaths report

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Issued 5 Aug 2025•West Sussex, Brighton and Hove

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.

View original report
Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
37

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised1

  1. Failure to provide sufficient designated clinical space for Emergency Department patients
    Part of recurring concern: Insufficient emergency-department capacity for timely patient carePart of recurring concern: Unsafe emergency-department crowding leaving patients without appropriate clinical space
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.27

  1. Action

    Publish data on the prevalence of corridor care to improve transparency and drive improvement.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  2. Action

    Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  3. Action

    Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025.

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

  1. Position

    NHS England is responsible for addressing the concerns and has already provided a response.

    Stated by Department of Health and Social CareRedirects 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

Failure to provide sufficient designated clinical space for Emergency Department patients

Wider context from the report

“During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so. The area is not designated as a clinical area. I understand that at the time of Mrs Batchelor's attendance on 25 February there were 25 patients in the Emergency Department corridor, and this increased to 32 patients. Clinicians from University Hospitals Sussex NHS Foundation Trust gave evidence as to the action that is being taken by the Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital. The evidence was however that, despite these actions, the corridor remains in use for patients currently as there is insufficient space within the department to care for patients. When asked there was no evidence as to when this practice would no longer be necessary. I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country when the capacities of Emergency Departments has been reached and there is nowhere to treat patients and the only other alternative would be to hold patients in ambulances outside of the hospital. A Prevention of Future Deaths report in relation to the use of the corridor for patient care was made during an investigation into a death which occurred in December 2022 and the use of the corridor remains ongoing. ”

Is this part of a recurring concern?

Yes — Insufficient emergency-department capacity for timely patient care; Unsafe emergency-department crowding leaving patients without appropriate clinical space.

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

Publish data on the prevalence of corridor care to improve transparency and drive improvement.

Verbatim wording from the response

“Regarding your concerns on corridor care, the provision of clinical care in corridors is unacceptable. We will publish data on the prevalence of corridor care for the first time to support transparency and drive improvement. NHS England has been working with trusts since 2024 to put in place new reporting arrangements. The data quality is currently being reviewed, and we expect to publish the information shortly.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 5 August 2025

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

Operate the Direct to Specialty Pathway Agreement with specialty acceptance, rapid in-reach, escalation via the bleep system, daily referral monitoring, and cross-specialty flow meetings.

Verbatim wording from the response

“We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Realign bed spaces and workforce through capacity-and-demand modelling to match service demand.

Verbatim wording from the response

“There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.”

Source location

2025-0406 - Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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 a hospital-wide no-corridor culture through nominated leaders, staff empowerment, rapid response, feedback, learning, recognition, and scenario-based training.

Verbatim wording from the response

“Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Educate high-presenting nursing homes about avoiding unnecessary emergency-department attendances and navigating alternative care.

Verbatim wording from the response

“One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Provide consultant advice to ambulance services at the point of contact to support appropriate emergency-department referrals and avoid unnecessary attendances.

Verbatim wording from the response

“I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8 -10 ambulance attendances are avoided each day.”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce emergency-department waits for ward admission.

Verbatim wording from the response

“The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.”

Source location

2025-0406 - Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Progress the Acute Floor Reconfiguration capital programme to improve patient flow, capacity, and the clinical environment.

Verbatim wording from the response

“As you know from the evidence heard at the inquest, the Medicine Divisional Leadership team, the Hospital Directors, and Executive team are continuously working on several separate but linked workstreams, which were previously in their infancy, to eradicate the use of the ED corridor for patient care and ensure they are treated in the most appropriate clinical environment with dignity and without delays.”

Source location

2025-0406 - Response from Hospital Trust
Page 1 · response
Published 5 August 2025

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

Coordinate with the local mental health trust to support rapid admission of patients requiring mental health care to appropriate units.

Verbatim wording from the response

“Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible.”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Lead the Hospital Alternative Oversight Programme to reduce inappropriate admissions and improve hospital flow and discharge through alternative-care, urgent-treatment, same-day, virtual, frailty, therapy, planning, and acuity initiatives.

Verbatim wording from the response

“We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:”

Source location

2025-0406 - Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Convert a trolley cubicle into a reclining-chair area in the emergency department to increase clinical space.

Verbatim wording from the response

“We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.”

Source location

2025-0406 - Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Publish Temporary Escalation Space usage data during 2025/26 to drive reductions in corridor care.

Verbatim wording from the response

“Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.”

Source location

Response from NHS England
Page 2 · response
Published 5 August 2025

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

Publish principles for providing safer care in Temporary Escalation Spaces when demand exceeds capacity.

Verbatim wording from the response

“The delivery of care in Temporary Escalation Spaces (TES) in EDs experiencing patient crowding (including providing care at beds and chairs) is not acceptable and should not be considered as standard. TES refers to care given in any unplanned settings (such as corridors) and, in September 2024, NHS England published a set of principles for supporting improved quality of care should patient demand outstrip capacity. These principles have been developed to support point-of-care staff to provide the safest, most effective and highest quality care possible when TES care has been deemed necessary, and the principles should be applied alongside any local standard operating procedures and arrangements governing flow pathways and safe staffing.”

Source location

Response from NHS England
Page 1 · response
Published 5 August 2025

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

Develop the operating model supporting providers to eliminate emergency-department crowding and corridor care.

Verbatim wording from the response

“In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we”

Source location

Response from NHS England
Page 1 · response
Published 5 August 2025

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

Develop services that shift unplanned urgent activity from acute hospitals to alternative settings and support proactive care and discharge.

Verbatim wording from the response

“are continuing to develop services that shift activity from acute hospital settings to settings outside of an acute hospital for patients with unplanned urgent needs, supporting proactive care, alternatives to admission and improving hospital discharge.”

Source location

Response from NHS England
Page 2 · response
Published 5 August 2025

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

Mandate daily reporting of Temporary Escalation Space use by acute hospitals in emergency departments and wards.

Verbatim wording from the response

“Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.”

Source location

Response from NHS England
Page 2 · response
Published 5 August 2025

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

Progress patient-flow improvements through Operational Planning guidance, including productivity, reduced length of stay and improved clinical outcomes.

Verbatim wording from the response

“In June 2025, NHS England published the Urgent and Emergency Care (UEC) Plan for 2025/26, which included an ambition to ‘improve flow through hospitals with a particular focus on patients waiting over 12 hours and making progress on eliminating corridor care’. NHS England is working through the operating model to support providers to eliminate crowding in EDs in the longer term. Improvements are being progressed through NHS England’s Operational Planning guidance, where healthcare systems were asked to focus on areas to deliver improved patient flow. This has included increasing the productivity of acute and non-acute hospital services, improving flow and length of stay, as well as clinical outcomes. In addition to this, we”

Source location

Response from NHS England
Page 1 · response
Published 5 August 2025

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

Work with regional teams to improve the quality, timeliness and completeness of Temporary Escalation Space data.

Verbatim wording from the response

“Furthermore, since January 2025, NHS England has mandated all acute hospitals to report daily TES usage in EDs and wards. Most are now submitting data, and NHS England is working with regional teams to improve its quality, timeliness and completeness. The goal is to begin publishing data during 2025/26, to drive reductions in the use of corridor care across the country and achieve the ambition set out in the UEC plan.”

Source location

Response from NHS England
Page 2 · response
Published 5 August 2025

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

Convert a trolley cubicle into a reclining-chair area in ED Majors to increase clinical space.

Verbatim wording from the response

“We have converted what was previously a trolley cubicle into a reclining chair area within Majors in ED to increase clinical space.”

Source location

Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Operate the Direct to Specialty Pathway Agreement, supported by specialty in-reach, rapid bleep escalation, daily referral monitoring and cross-specialty flow meetings.

Verbatim wording from the response

“We now have a Direct to Specialty Pathway Agreement between ED and the Trust’s specialties so certain categories of patient are accepted by the relevant specialty on presentation to the ED. Our Interim General Manager for Medicine and Urgent Care (Brighton and Haywards Heath) is the Responsive workstream lead for this, and data is collected daily for all specialty referrals from ED, to monitor the response times from the specialties. Specialties in-reach to ED/AMU/SDEC and we operate a 3/2/1 bleep system to ensure this is fast and effective. There are regular cross specialty flow meetings over the course of the day.”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Educate teams at ten local nursing homes about avoidable ED attendances and alternatives to ED care.

Verbatim wording from the response

“One of our Frailty Consultants is working with the 10 local Nursing Homes which have the highest number of presentations of their residents to ED, to educate their teams on non necessary attendances to ED and providing them with confidence in navigating alternatives to the ED.”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Lead a hospital-wide no-corridor culture programme using nominated leaders, staff empowerment, response targets, feedback, recognition and scenario-based training.

Verbatim wording from the response

“Our Interim Assistant Director for Leadership and Management is leading on a cultural mindset change throughout the hospital, so we have a ‘no corridor culture’. This includes nominated leaders, staff empowerment, a 4 hour response timeline, celebration of teams preventing corridor use, regular feedback and learning loops, and scenario based training to reinforce the cultural mindset change.”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Realign bed spaces and matching workforce through capacity-and-demand modelling.

Verbatim wording from the response

“There is a Capacity and Demand modelling piece of work underway which is realigning areas with increased bed spaces to areas with less bed spaces with workforce changes to match the demand.”

Source location

Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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 Acute Floor Reconfiguration capital programme to improve capacity, patient flow and the clinical environment.

Verbatim wording from the response

“Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County Hospital, is well underway.”

Source location

Response from Hospital Trust
Page 1 · response
Published 5 August 2025

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

Lead the Hospital Alternative Oversight Programme to avoid inappropriate admissions, improve hospital flow and smooth discharge through alternative-care and same-day emergency initiatives.

Verbatim wording from the response

“We have an Operational Flow Improvement Manager in post who is leading the Hospital Alternative Oversight Programme (HALO). This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Operate the Continuous Flow Model to move patients earlier from the Acute Floor and reduce ED waits for ward admission.

Verbatim wording from the response

“The Continuous Flow Model has improved the earlier movement of patients from the Acute Floor and reduced the time patients are waiting in the ED for admission to a ward.”

Source location

Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Provide Trust consultant advice at ambulance point of contact with SECAmb to direct only patients requiring emergency care to the ED.

Verbatim wording from the response

“I am pleased to say that we are working closely with SECAmb by having a Consultant of ours giving advice at the point of contact to ensure only the correct patients (those in need of emergency care) are coming to the ED. This work has demonstrated that 8-10 ambulance attendances are avoided each day.”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

NHS England is responsible for addressing the concerns and has already provided a response.

Verbatim wording from the response

“In preparing this response, my officials have made enquiries with NHS England and I understand they have already responded to address your concerns.”

Source location

Response from Department for Health and Social Care
Page 1 · response
Published 5 August 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.10

  1. 1

    Invest £250 million to expand same-day and urgent care services, supporting faster diagnosis, treatment, discharge and avoidance of unnecessary admissions.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  2. 2

    Increase urgent-care provision in primary, community and mental-health settings.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  3. 3

    Introduce clinical operational standards for the first 72 hours of care, covering timely review, advice availability and coordinated specialist care.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  4. 4

    Increase urgent-care capacity outside hospitals through new neighbourhood health services.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 August 2025.
  5. 5

    Share the coroner’s concerns with the Trust-wide Patient Safety Group to promote organisation-wide learning and engagement.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  6. 6

    Change the emergency-department medical care model to provide a GP of the day for the ambulatory patient area.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  7. 7

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

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  8. 8

    Change the ED medical model to provide a GP of the day for the ambulatory patient area.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  9. 9

    Share the coroner’s concerns with the Trust-wide Patient Safety Group to promote learning and engagement.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 August 2025.
  10. 10

    Work with the local Mental Health Trust to expedite admission of patients requiring mental health hospital care to appropriate units.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025.

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

Invest £250 million to expand same-day and urgent care services, supporting faster diagnosis, treatment, discharge and avoidance of unnecessary admissions.

Verbatim wording from the response

“• Investing £250 million into expanding same day and urgent care services, helping avoid unnecessary admissions to hospital and supporting faster diagnosis, treatment and discharge for patients.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 5 August 2025

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

Increase urgent-care provision in primary, community and mental-health settings.

Verbatim wording from the response

“• Increasing the number of patients receiving urgent care in primary, community and mental health settings.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 5 August 2025

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

Introduce clinical operational standards for the first 72 hours of care, covering timely review, advice availability and coordinated specialist care.

Verbatim wording from the response

“• Introducing new clinical operational standards for the first 72 hours of care to support better hospital flow. These set minimum expectations for timely review, availability of advice, and coordinated care when multiple specialist teams are involved.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 5 August 2025

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

Increase urgent-care capacity outside hospitals through new neighbourhood health services.

Verbatim wording from the response

“• In the longer-term, our 10 Year Health Plan will increase the urgent care capacity outside hospital through new neighbourhood health services, reducing demand pressures on A&E.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 5 August 2025

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

Share the coroner’s concerns with the Trust-wide Patient Safety Group to promote organisation-wide learning and engagement.

Verbatim wording from the response

“Your Regulation 28 report has been carefully considered by the Executive team, and the Medicine Division, including the Chief of Service for Medicine and the Divisional Director of Nursing for Medicine. Your concerns have also been shared at the Trust wide Patient Safety Group meeting to ensure widespread learning and engagement.”

Source location

2025-0406 - Response from Hospital Trust
Page 1 · response
Published 5 August 2025

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

Change the emergency-department medical care model to provide a GP of the day for the ambulatory patient area.

Verbatim wording from the response

“We have changed our Medical Model of Care in ED so there is a GP of the day supporting our ambulatory patient area.”

Source location

2025-0406 - Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future 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 events, such as the sad death of Maureen, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 5 August 2025

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

Change the ED medical model to provide a GP of the day for the ambulatory patient area.

Verbatim wording from the response

“We have changed our Medical Model of Care in ED so there is a GP of the day supporting our ambulatory patient area.”

Source location

Response from Hospital Trust
Page 3 · response
Published 5 August 2025

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

Share the coroner’s concerns with the Trust-wide Patient Safety Group to promote learning and engagement.

Verbatim wording from the response

“Your Regulation 28 report has been carefully considered by the Executive team, and the Medicine Division, including the Chief of Service for Medicine and the Divisional Director of Nursing for Medicine. Your concerns have also been shared at the Trust wide Patient Safety Group meeting to ensure widespread learning and engagement.”

Source location

Response from Hospital Trust
Page 1 · response
Published 5 August 2025

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

Work with the local Mental Health Trust to expedite admission of patients requiring mental health hospital care to appropriate units.

Verbatim wording from the response

“Furthermore, we work closely with the local Mental Health Trust, SPFT, as part of HALO to try to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible.”

Source location

Response from Hospital Trust
Page 2 · response
Published 5 August 2025

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

Official responses located
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Data last updated 7 September 2026