Ellen Lillian MacFarlane · Prevention of Future Deaths report

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Issued 4 Nov 2022•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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

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 raised3

  1. Unavailability of out-of-hours cardiac testing in District General Hospitals
    Part of recurring concern: Unreliable access to clinically required cardiology tests
  2. Delays in ambulance response caused by insufficient ambulance crews and vehicles
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
  3. Delays in deciding when to operate after further tests are pending over weekends

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. Department of Health and Social Care

    Publish the delivery plan for recovering urgent and emergency care services.

  2. Department of Health and Social Care

    Continue working with NHS England to reduce ambulance waiting and response times.

  3. Department of Health and Social Care

    Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.

  4. Department of Health and Social Care

    Publish information on ambulance handover times.

  5. Department of Health and Social Care

    Increase ambulance workforce capacity through investment in NHS ambulance and support staff.

  6. Department of Health and Social Care

    Deliver 5,000 additional staffed, permanent hospital beds and maintain the resulting capacity uplift in 2024/25.

  7. Department of Health and Social Care

    Deliver new ambulances and specialist mental health vehicles to increase ambulance capacity.

  8. Department of Health and Social Care

    Scale up virtual ward capacity to more than 10,000 beds nationally.

  9. Department of Health and Social Care

    Provide funding to support timely and effective hospital discharge by the NHS and local authorities.

  10. Department of Health and Social Care

    Provide additional funding to expand ambulance capacity and improve response times.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Department of Health and Social Care

    Existing Trust governance addresses delays beyond 36 hours for fractured-hip surgery, including capacity reviews and root-cause analysis.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. Department of Health and Social Care

    Emergency cardiac scans outside normal hours are addressed by transferring patients to a tertiary centre.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  3. Department of Health and Social Care

    Ambulance performance is reviewed through the existing Strategic Partnership and Transformation Board.

    Existing 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

Unavailability of out-of-hours cardiac testing in District General Hospitals

Wider context from the report

“2. Evidence before the inquest indicated that over a weekend Ellen MacFarlane required cardiac tests that could not be provided easily in a District General Hospital setting due to availability of services/staff at DGHs out of hours. As a consequence where an operation for a fractured neck of femur has been put on hold pending further tests there is an inbuilt additional delay over a weekend before a decision can be taken as to the optimum point at which to operate. This situation at DGHs appears to create a situation which is inconsistent with the drive to operate at the earliest possible point when a patient has been optimised to secure the best outcome as set out in the NICE Guidance. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required cardiology tests.

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 ambulance response caused by insufficient ambulance crews and vehicles

Wider context from the report

“1. The inquest heard evidence that notwithstanding her age and frailty Ellen MacFarlane had to wait over 5 hours for an ambulance. This was due to the demands on the North West Ambulance Service on the day in question. The inquest heard that such delays were not unusual and were still occurring. The reason for the delay was a shortage of ambulance crews/vehicles due to a combination of high demand, staffing shortages and delays at ED; ”

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

Delays in deciding when to operate after further tests are pending over weekends

Wider context from the report

“2. Evidence before the inquest indicated that over a weekend Ellen MacFarlane required cardiac tests that could not be provided easily in a District General Hospital setting due to availability of services/staff at DGHs out of hours. As a consequence where an operation for a fractured neck of femur has been put on hold pending further tests there is an inbuilt additional delay over a weekend before a decision can be taken as to the optimum point at which to operate. This situation at DGHs appears to create a situation which is inconsistent with the drive to operate at the earliest possible point when a patient has been optimised to secure the best outcome as set out in the NICE Guidance. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 the delivery plan for recovering urgent and emergency care services.

Verbatim wording from the response

“As the Minister responsible for urgent and emergency care services, I recognise the significant pressure the urgent and emergency care system is facing. That is why we published our ‘Delivery plan for recovering urgent and emergency care services’ which aims to deliver sustained improvements in waiting times. Our ambitions for this year are to improve A&E waiting times to 78% of patients to be admitted, transferred, or discharged from A&E within”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 7 November 2022

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

Continue working with NHS England to reduce ambulance waiting and response times.

Verbatim wording from the response

“However, I recognise there is still more to do to reduce waiting/response times further, and the Government will continue to work with NHS England to achieve this.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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

Maintain the additional ambulance capacity funded for 2023/24 during 2024/25.

Verbatim wording from the response

“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 information on ambulance handover times.

Verbatim wording from the response

“At a national level, we have seen significant improvements in performance this year compared to last year. In 2023-24, year to date average Category 2 ambulance response times (including for serious conditions such as heart attacks and strokes) were almost 15 minutes faster compared to the same period last year, a reduction of over 27%. NWAS average Category 2 response times were over 13 minutes faster compared to the same time period last year, a 32% reduction. Information on ambulance handover times has been published since October 2023. In March 2024, average patient handover times in the NWAS region were 32 minutes 51 seconds.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 ambulance workforce capacity through investment in NHS ambulance and support staff.

Verbatim wording from the response

“Regarding staffing capacity, we have made significant investments in the ambulance workforce – the number of NHS ambulance staff and support staff has increased by over 50% since 2010. To help ensure we have the ambulance workforce to meet the future demands on the service, the NHS Long Term Workforce Plan sets out plans to boost the number of paramedics by up to 15,600 to support future demand.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 5,000 additional staffed, permanent hospital beds and maintain the resulting capacity uplift in 2024/25.

Verbatim wording from the response

“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 new ambulances and specialist mental health vehicles to increase ambulance capacity.

Verbatim wording from the response

“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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

Scale up virtual ward capacity to more than 10,000 beds nationally.

Verbatim wording from the response

“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 funding to support timely and effective hospital discharge by the NHS and local authorities.

Verbatim wording from the response

“I recognise that ambulance trusts work within a health and care system and issues such as delayed patient handovers to hospitals can impact on capacity and response times. That is why a key part of the delivery plan is about improving patient flow and bed capacity within hospitals. We achieved our 2023/24 ambition of delivering 5,000 more staffed, permanent hospital beds this year compared to 2022-23 plans, backed by £1 billion of dedicated funding, and we will maintain this capacity uplift in 2024/25. Further, we also achieved our target of scaling up virtual ward bed capacity to over 10,000 ahead of winter 2023/24, and there are now over 11,000 beds available nationally. We have also provided £1.6 billion of funding over two years to support the NHS and local authorities to ensure timely and effective discharge from hospital.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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 additional funding to expand ambulance capacity and improve response times.

Verbatim wording from the response

“Your report highlights that NWAS were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 7 November 2022

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

Existing Trust governance addresses delays beyond 36 hours for fractured-hip surgery, including capacity reviews and root-cause analysis.

Verbatim wording from the response

“My officials have consulted NHS England (NHSE) and the Care Quality Commission (CQC) regarding your concern over the availability of cardiac tests over the weekend. We are advised that, had there been an emergency need for scans outside of hours, that Ms MacFarlane would have been transferred to a tertiary centre. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance for patients with a fractured neck of femur requiring surgery. This includes urgent review of theatre capacity by the divisional management team to schedule surgeries as soon as possible, and root cause analysis of misses to identify reasons for delays and opportunities for learning.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 7 November 2022

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

Emergency cardiac scans outside normal hours are addressed by transferring patients to a tertiary centre.

Verbatim wording from the response

“My officials have consulted NHS England (NHSE) and the Care Quality Commission (CQC) regarding your concern over the availability of cardiac tests over the weekend. We are advised that, had there been an emergency need for scans outside of hours, that Ms MacFarlane would have been transferred to a tertiary centre. More broadly the Trust has governance in place to reduce delays outside the 36-hour timeframe to support compliance with NICE guidance for patients with a fractured neck of femur requiring surgery. This includes urgent review of theatre capacity by the divisional management team to schedule surgeries as soon as possible, and root cause analysis of misses to identify reasons for delays and opportunities for learning.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 7 November 2022

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

Ambulance performance is reviewed through the existing Strategic Partnership and Transformation Board.

Verbatim wording from the response

“Your report raises concerns about ambulance response times by North West Ambulance Service NHS Trust (NWAS) and access to hospital services. In preparing this response, Departmental officials have made enquiries with NHS England. I have been reassured by NWAS that ambulance performance is reviewed regularly via the Strategic Partnership and Transformation Board, a joint committee between NWAS and the Integrated Care Boards in the region and I am pleased to note performance by NWAS has improved since this sad case.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 7 November 2022

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