PFD report

Ronald William Bennett · Prevention of Future Deaths report

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Issued 5 Apr 2017•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.

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Concerns
2

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
12

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 raised2

  1. Lack of hospital bed availability delaying patient admission
    Part of recurring concern: Failure to provide timely hospital admissionPart of recurring concern: Insufficient acute hospital capacity for patients requiring admissionPart of recurring concern: Unsafe pressure on hospital admission and discharge decisions from bed capacity constraints
  2. Failure to complete hospital handovers within the 30-minute national standard
    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.11

  1. Action

    Introduce an Immediate Handover Policy for ambulance-to-hospital transfers.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
  2. Action

    Develop and implement a joint handover standard operating procedure with BSUH, defining responsibilities and escalation processes.

    Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2017.
  3. Action

    Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.

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

  1. Position

    Existing system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.

    Stated by South East Coast Ambulance Service NHS Foundation TrustExisting 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

Lack of hospital bed availability delaying patient admission

Wider context from the report

“(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day). (2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate. (3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds. (4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death. (5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH. ”

Is this part of a recurring concern?

Yes — Failure to provide timely hospital admission; Insufficient acute hospital capacity for patients requiring admission; Unsafe pressure on hospital admission and discharge decisions from bed capacity constraints.

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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

Failure to complete hospital handovers within the 30-minute national standard

Wider context from the report

“(1) There are serious delays in ambulance crews arriving at the scene of an incident as a consequence of ambulance crews being delayed at the Accident and Emergency department as they are unable to handover patients within the national standard for hospital handovers at A and E of 30 minutes. I heard evidence that on the 20 February 2016, out of 105 patients conveyed to hospital, 91 patients were delayed over 30 minutes (95.55%), 2 patients over 120 minutes. The hours lost to handover and turnaround delays from April 2015-January 2017 at the Royal Sussex County Hospital Brighton were 12779.70. ( an average of 580.9 per month/19.9 hours a day). (2) Care Quality Commission report published 23.10.2015-urgent - emergency services found to be inadequate. (3) Reasons for delay in hospital handovers were various involving not only the Accident and Emergency department but the inability of the hospital to admit patients because of lack of availability of beds. (4) It should be noted that in respect of Mr.Bennett, that although there was a significant delay in him being admitted to hospital, this did not contribute to his death. (5) It should also be noted that some steps are being taken to address these issues and there is cooperation between SECAMB and the RSCH. ”

Is this part of a recurring concern?

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

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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

Introduce an Immediate Handover Policy for ambulance-to-hospital transfers.

Verbatim wording from the response

“In recent years, the delays at hospitals for ambulance crews has continually increased, to the point where they are impacting on the Trust’s ability to respond to emergency calls in the community. During 2015, in response to this ever growing problem, we introduced an Immediate Handover Policy. However, due to the challenges at the Royal Sussex County Hospital this was difficult to implement. A special Handover Workshop was facilitated last year in Brighton by Professor Matthew Cooke who had previously been National Clinical Director for Emergency & Urgent Care for the NHS. This was organised by Emergency Care Improvement Programme to seek solutions as the delays at Brighton & Sussex University Hospitals NHS Trust had been rising.”

Source location

2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 28 July 2017

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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

Develop and implement a joint handover standard operating procedure with BSUH, defining responsibilities and escalation processes.

Verbatim wording from the response

“In March 2017, a new joint Standard Operating Procedure was developed in partnership with BSUH providing more clarity around the process and responsibilities, including how and when to escalate. Since its implementation, there has been a marked improvement in overall performance in handover delays, although it is still the case that many hours continue to be lost.”

Source location

2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 1 · response
Published 28 July 2017

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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

Develop a £31 million capital scheme expanding the emergency floor, Urgent Care Centre, Emergency Department GP input and ambulatory emergency care at Royal Sussex County Hospital.

Verbatim wording from the response

“(3) We now have a £31m capital scheme in development to expand the emergency floor, including an expanded Urgent Care Centre at the Royal Sussex County Hospital, more GP input to the Emergency Department and an ambulatory emergency care facility in advance of next winter.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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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

Commission an observational audit of the ambulance handover process to identify further improvements.

Verbatim wording from the response

“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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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

Extend the Hospital at Home scheme to provide additional nursing and medical support after discharge.

Verbatim wording from the response

“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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 joint clinical handover protocol and escalation triggers at 15, 30 and 60 minutes after patient arrival.

Verbatim wording from the response

“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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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

Expand Newhaven Downs Community Hospital to create additional discharge capacity.

Verbatim wording from the response

“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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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

Implement the SAFER care bundle to improve patient flow and support earlier discharge.

Verbatim wording from the response

“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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

Fund a joint Hospital Ambulance Liaison Officer appointment.

Verbatim wording from the response

“As part of the development of closer working relations with SECAMB, the two organisations have agreed and implemented a new clinical handover protocol and escalation triggers at 15, 30 and 60 minutes from arrival of a patient to ensure more timely handover. The Trust is also funding the joint appointment of a Hospital Ambulance Liaison Officer and we have commissioned an observational audit of the handover process to identify any further improvements that can be made.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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

Review service provision at Princess Royal Hospital to relieve pressure on Royal Sussex County Hospital bed capacity.

Verbatim wording from the response

“(4) The Trust’s Clinical Transformation Programme includes the following measures:”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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 more closely with South East Coast Ambulance Service to improve ambulance handover processes.

Verbatim wording from the response

“Since January 2017, there have been significant efforts to work more closely with South East Coast Ambulance Service NHS Foundation Trust (SECAMB) and this has been reflected in improved ambulance handover performance. In March 2017 the ambulance handover performance was the best for two years.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 28 July 2017

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 system-partner arrangements are considered sufficient to prioritise the problem and sustain improvement, although the problem is not yet resolved.

Verbatim wording from the response

“Although I cannot give you assurance that this complex and multi-factorial problem is fixed, I am confident that the matter is now being given sufficient priority by our acute, community and primary care partners. Its impact on our services is significant, and we are doing all we reasonably can to ensure improvement is sustained.”

Source location

2017-0097-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
Page 2 · response
Published 28 July 2017

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.1

  1. 1

    Work with NHS 111 to improve the Directory of Services and direct patients to appropriate alternatives to the Emergency Department.

    Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.

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 NHS 111 to improve the Directory of Services and direct patients to appropriate alternatives to the Emergency Department.

Verbatim wording from the response

“(2) We are working with NHS 111 on our Directory of services to ensure patients are directed to appropriate services other than the Emergency Department.”

Source location

2017-0097-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 28 July 2017

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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