Recurance · prevention of future deaths reports
Pre-inquest brief
Patient flow problems leading to ambulance handover delays
The earlier warning
Lilly Baxandall · 17 May 2017 · John Gittins, North Wales (East and Central)
“substantial delays in the handover of patients particularly as a result of problems in patient flow”
judiciary.uk/prevention-of-future-death-reports/lilly-baxandall
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 6 Jun 2018 · Ester Wood · David Pojur · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Lilly Baxandall · 17 May 2017
“substantial delays in the handover of patients particularly as a result of problems in patient flow”
Later · Ester Wood · 6 Jun 2018
“patient flow and the multifactorial problems associated with cases of this nature have been reported upon by this Court on several occasions”
What happened next
No web check of the stated actions has been published for this chain.