PFD report

Patricia Grace Eileen Green · Prevention of Future Deaths report

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Issued 4 Feb 2023•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
6

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 Emergency Department assessment and treatment
  2. Delays in ambulance availability
    Part of recurring concern: Delays in ambulance attendancePart of recurring concern: Insufficient ambulance service capacity for emergency calls
  3. Delays in ambulance crew offload at Emergency Departments
    Part of recurring concern: Delays in ambulance-to-hospital patient handover
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.6

  1. Action

    Deliver new ambulances and specialist mental health vehicles.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2023.
  2. Action

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

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 February 2023.
  3. Action

    Provide 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 February 2023.

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 Emergency Department assessment and treatment

Wider context from the report

“1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients; 2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest; 3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 availability

Wider context from the report

“1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients; 2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest; 3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients. ”

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 ambulance crew offload at Emergency Departments

Wider context from the report

“1. Mrs Green had a long wait for an ambulance, despite her age and the recognised risks of being on the floor for a prolonged period of time, due to a shortage of ambulances. Mrs Green deteriorated whilst waiting to be taken to hospital. The Inquest heard that the shortage of ambulances was due to a number of factors including high demand and a shortage of crews due to long delays at Emergency Departments (ED) across the Greater Manchester to offload patients; 2. The evidence before the Inquest was that the delay on the day Mrs Green was waiting for an ambulance was not unusual and still remained the case on the day of the Inquest; 3. The Inquest heard that Mrs Green’s wait of 3 hours in ED was not unusual and was due to the volume of patients waiting to be seen and the overall demand on ED. The consequence was that elderly frail patients were receiving treatment that was delayed and in circumstances that were challenging for frail patients. ”

Is this part of a recurring concern?

Yes — Delays in ambulance-to-hospital patient handover.

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

Deliver new ambulances and specialist mental health vehicles.

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 20 February 2023

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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

Scale 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 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 20 February 2023

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 5,000 additional staffed, permanent hospital beds and maintain the capacity uplift.

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 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 20 February 2023

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 additional ambulance capacity to expand provision 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 20 February 2023

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 discharge from hospital.

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 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 20 February 2023

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 response times.

Verbatim wording from the response

“However, I recognise there is still more to do to reduce 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 20 February 2023

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