Recurance · prevention of future deaths reports
Pre-inquest brief
Delayed emergency department treatment due to overcrowding
The earlier warning
Patricia Green · 4 Feb 2023 · Alison Mutch, Manchester South
“Mrs [name redacted] 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.”
judiciary.uk/…/patricia-green-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Patricia Green (4 Feb 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/…/2023-0044-Response-from-Department-of-Health-and…
What recurred
- 9 Apr 2025 · Bernard Lyon · Alison Mutch · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Patricia Green · 4 Feb 2023
“Mrs [name redacted] 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.”
Later · Bernard Lyon · 9 Apr 2025
“The Emergency Department at TGH was extremely busy on the day Mr [name redacted] arrived which was not unusual. The sheer volume of patients who were seriously ill meant that there was a delay in him being given antibiotics in accordance with his need.”
What happened next
No evidence found either way · a stated action in a response
The source does not mention any promised action by the Department of Health and Social Care regarding the CQC replying separately.
No evidence found does not mean the action did not happen.