Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Reginald Collins · 30 Jul 2020 · Alison Mutch, Manchester South
“The delay in his discharge via Adult Social Care meant that an acute hospital bed was not available to the Trust.”
judiciary.uk/prevention-of-future-death-reports/reginald-collins
What was promised
Stated action 1 · response to Kenneth Heard (23 Nov 2023) · stated timescale: March 2025
“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 four hours by March 2025, and to reduce Category 2 ambulance response times to 30 minutes on average across this fiscal year.”
judiciary.uk/…/2023-0473-Response-from-Department-of-Health-and…
Stated action 2 · response to Dennis Harry (22 Sept 2024) · stated timescale: none stated
“making space for a Clinical Decision Unit model, for patients who need more clinical care but don't need to be admitted to hospital”
Stated action 3 · response to Andrew Waters (3 Apr 2025) · stated timescale: March 2026
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
2 further stated actions are listed on the full chain page.
What recurred
- 23 Nov 2023 · Kenneth Heard · Guy Davies
- 22 Sept 2024 · Dennis Harry · Guy Davies · Identical hazard · confidence 0.90 (high)
- 2 Dec 2024 · Junior Powell · Fiona Wilcox · Closely related · confidence 0.90 (high)
- 3 Apr 2025 · Andrew Waters · Guy Davies · Identical hazard · confidence 0.90 (high)
- 12 May 2025 · James Smith · Guy Davies · Identical hazard · confidence 0.95 (high)
- 18 Jun 2026 · Geoffrey Fuller · Guy Davies · Closely related · confidence 0.90 (high)
- 10 Aug 2026 · Pamela Hindley · Guy Davies · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Andrew Waters · 3 Apr 2025
“Insufficient social care provision leading to large numbers of patients in hospital who are otherwise fit for discharge, thereby impeding patient flow through hospital.”
Later · Pamela Hindley · 10 Aug 2026
“The court found significant numbers of patients in hospital who are medically fit for discharge and with no reason to reside in hospital (NCTR) but cannot be discharged due to lack of available social care provision (whether commissioned by social services or NHS).”
What happened next
No evidence found either way · stated action 1
“Patients will receive better, faster and more appropriate emergency care as the government sets out reforms to shorten waiting times in A&E”
New ambulances and faster emergency care for patients next winter - GOV.UK · gov.uk/…/new-ambulances-and-faster-emergency-care-for-patients-…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“We hope to launch our brand new HSMA-λ (HSMA lambda) courses, aimed at leaders and decision makers, in *winter 2026/27 - spring 2027*, and HSMA 7 in *spring/summer 2027”
Modelling the potential impact of having a Clinical Decision Unit – HSMA · hsma.co.uk/…/H1_1005_modelling_potential_impact_of_clinical_div…
“Improvement Leaders' Guide will help you to understand the theory associated with 'improving flow' and offer practical tips on its application.”
[PDF] Improving flow - NHS England · england.nhs.uk/…/ILG-2.3-Improving-Flow.pdf
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Hospitals in England should create "extended emergency medicine ambulatory care" (EEMAC) areas to accommodate patients facing longer waits who can be safely investigated and managed during a prolonged emergency department stay, according to new guidance from NHS”
NHS Backs New A&E Care Areas for Patients Facing Long Waits · medscape.com/…/nhs-backs-new-a-e-care-areas-patients-facing-lon…
No evidence found does not mean the action did not happen.
A source suggests the action was not carried out as stated · stated action: “On 6 June 2025, we published our Urgent and Emergency Care Plan for 2025/26. The plan requires the NHS to focus on those activities that will have the biggest impact on improving urgent and emergency care performance, including ambulance response and handover times: - at least 78% of patients in A&E departments will be seen within 4 hours.”
“Across England, the proportion of handovers exceeding 60 minutes has increased steadily since May 2021, and towards the end of 2022 accounted for more than a fifth of handovers. Over the same time, [name redacted] share of >60-minute handovers has exceeded five-percent on just two occasions.”
National Ambulance Handover Delays · aace.org.uk/…/Effective-interventions-in-managing-hospital-hand…
“An expectation of ambulance handover within 15 min of arrival at EDs was stipulated by the Department of Health and Social Care in England more”
How are handover delays from ambulances to emergency ... · link.springer.com/article/10.1186/s12873-026-01532-9
“Zero tolerance - Making ambulance handover delays a thing of the past, NHS Confederation 2012 Introduction This paper focuses on practical approaches to help reduce ambulance-to-hospital handover delays. Patient handover delays are not solely the responsibility of ambulance services and emergency departments. Delays are often associated with compromised 'down-stream' flow in acute hospitals and”
Improving Ambulance Handover – Practical Approaches · england.nhs.uk/wp-content/uploads/2013/08/amb-hand.pdf