PFD report

Elizabeth Muriel Leah · Prevention of Future Deaths report

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Issued 19 Feb 2015•Manchester South

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
0

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 raised3

  1. Delays in getting patients into A and E departments
    Part of recurring concern: Failure to maintain safe hospital patient flowPart of recurring concern: Failure to provide timely hospital admission
  2. Insufficient ambulance and staff capacity for timely ambulance response
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
  3. Bed blocking throughout hospital systems
Responses linked to these concerns

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

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

  1. Position

    Local commissioners are responsible for ensuring ambulance services receive sufficient funding for local population needs.

    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

Delays in getting patients into A and E departments

Wider context from the report

“On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi. This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi. When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time. This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems. These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe hospital patient flow; Failure to provide timely hospital admission.

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

Insufficient ambulance and staff capacity for timely ambulance response

Wider context from the report

“On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi. This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi. When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time. This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems. These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance; Insufficient ambulance service capacity for emergency calls.

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

Bed blocking throughout hospital systems

Wider context from the report

“On the occasion when she fell, an ambulance was called using the 999 system. On describing the circumstances, the Care Staff were told that they would get a call back from NHS within 60 minutes. They were also informed that there would be a delay of up to 6 hours for the ambulance to arrive. 50 minutes later the ambulance service called back and advised that she should be taken to hospital in a Taxi. This meant that an 87 year old lady with severe dementia and a broken leg, was delivered to the hospital Emergency Department in a wheelchair in a Taxi. When I questioned the Ambulance service Manager about this, she was very candid and accepted that the problem is that they do not have sufficient ambulances or staff available and that they are working “at 100%” all the time. This problem is exacerbated by the delays in getting patients into the A and E Departments, which in turn is exacerbated by the bed blocking throughout the hospital systems. These are not problems which can be alleviated locally, but require an urgent input and direction from Central Government. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Local commissioners are responsible for ensuring ambulance services receive sufficient funding for local population needs.

Verbatim wording from the response

“I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.”

Source location

2015-0064-Response-by-Department-of-Health
Page 1 · response
Published 19 February 2015

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

Individual ambulance Trusts are responsible for determining clinicians, vehicles and equipment needed to respond according to patients’ clinical needs.

Verbatim wording from the response

“I should stress that although NHS England maintains oversight of the day-to-day operation of the commissioning side of the NHS in England, it is for local commissioners to ensure that ambulance services receive sufficient funding according to the needs of their local populations. Individual Trusts must ensure a high quality service which includes determining the type of clinician, vehicle and equipment required to respond to calls based on the clinical needs of the patient.”

Source location

2015-0064-Response-by-Department-of-Health
Page 1 · response
Published 19 February 2015

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