PFD report

Shaun Mansell · Prevention of Future Deaths report

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Issued 1 Nov 2021•Stoke-on-Trent and North Staffordshire

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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: 1
Recipients: 2
Responses found: 2
Stated actions: 17

Recipients and published responses

NHS England

Response foundRoyal Stoke University HospitalNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 02/08/2021 I commenced an investigation into the death of Shaun Mansell, aged 50. The investigation concluded at the end of the inquest on 1st November 2021. The conclusion of the inquest was Shaun Mansell died of natural causes.

Sean Mansell had a medical history of alcohol dependence syndrome. On the 5th July 2021, the West Midlands Ambulance Service received a 999 call at 19.23 hours from a neighbour of the deceased who reported that the deceased couldn't walk. The call was allocated a category 3 disposition which had a target response time frame of 120 minutes. An ambulance arrived on scene at 03.38 on the 6th July which was 8 hours and 15 minutes later and not within the response time frame. This was due to the fact that demand outstripped available resources.

A welfare call was undertaken at 21.28 hours by a paramedic who had been asked to go into the control room to assist with welfare calls due to the high volume of 999 calls outstanding. The paramedic had not received prior training on how to complete these calls. The welfare call was conducted with the neighbour. No contact was made directly with the deceased during the 8 hour delay which led to a missed opportunity to identify a change in his condition. When the ambulance arrived, the deceased had passed away on the sofa in his front room. There was evidence of blood loss on the floor next to the deceased and around his mouth. The police did not find any suspicious circumstances. A post mortem examination found the cause of death to be acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism. The medical evidence was not able to determine if the delay in the arrival of the ambulance contributed to the death because there was no certainty of timeline about the bleeding.
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Concerns and recipient responses

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

Concerns raised1

Excessive delays in handing over patients at hospital
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 9

Action
Support systems to improve hospital flow by reducing length of stay and enabling timely discharge.
Stated by NHS EnglandStated in progress
Action
Reiterate communications to systems on eliminating ambulance handover delays and share measures addressing those delays.
Stated by NHS EnglandStated completed
Action
Make additional winter funding available to support investment in Hospital Ambulance Liaison Officer staff.
Stated by NHS EnglandStated completed

Respondent positions 3

Position
Resolving ambulance delays requires action by ambulance, primary care, mental health, community and social care providers, not this Trust alone.
Stated by University Hospitals of North Midlands NHS TrustRedirects responsibility

Other statements in published responses

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

Recipient-stated actions 8

1
Work with the ambulance service to enable Community Rapid Intervention Service access to its information system for direct review and removal of suitable waiting patients.
Stated by University Hospitals of North Midlands NHS TrustStated in progress
2
Work with commissioning and urgent care partners to enhance Urgent Care Centre pathways and divert patients from the emergency department.
Stated by University Hospitals of North Midlands NHS TrustStated in progress
3
Use GP Connect to enable direct communication between primary care and hospital teams and reduce avoidable emergency department referrals.
Stated by University Hospitals of North Midlands NHS TrustStated completed
4
Position Community Rapid Intervention Service staff inside the emergency department to redirect inappropriate ambulance conveyances and attendances.
Stated by University Hospitals of North Midlands NHS TrustStated completed
5
Provide 111 kiosks at both emergency departments to direct patients toward alternative care pathways.
Stated by University Hospitals of North Midlands NHS TrustStated completed
6
Maintain separate hot and cold ambulance arrival areas to segregate COVID and non-COVID arrivals.
Stated by University Hospitals of North Midlands NHS TrustStated completed
7
Position a nurse navigator at the emergency department front door to redirect suitable ambulatory non-acute patients.
Stated by University Hospitals of North Midlands NHS TrustStated completed
8
Provide ambulance service access to same-day acute pathways as an alternative to emergency department conveyance.
Stated by University Hospitals of North Midlands NHS TrustStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised1

Excessive delays in handing over patients at hospital

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.9

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

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.8

Actions described in response 9

Respondent positions 3

Recipient-stated actions 8