Recurance · prevention of future deaths reports
Pre-inquest brief
Overcrowded emergency department leading to delays
The earlier warning
Samuel Garner · 27 Jul 2020 · Alison Mutch, Greater Manchester South
“The inquest heard evidence that on admission to Stepping Hill Hospital the Emergency Department was extremely busy due to the volume of patients in the department.”
judiciary.uk/prevention-of-future-death-reports/samuel-garner
What was promised
Stated action 1 · response to Samuel Garner (27 Jul 2020) · stated timescale: April 2022
“The new approach will incorporate two elements: - Implementation of the new national NHS 111 First Initiative, which will ask patients to call 111 prior to attending an Emergency Department - A new pre-Emergency Department triage and streaming system Both of these will help ensure patients are streamed or referred to the most appropriate service for their needs. This will include a wide range of community and acute-based services and will ensure only patients who need an Emergency Department go”
Stated action 2 · response to Samuel Garner (27 Jul 2020) · stated timescale: none stated
“We must do all we can to learn from what happened to Mr [name redacted] and improve the safety and quality of NHS care and I expect the Stockport NHS Foundation Trust and its local system partners to reflect carefully on the findings of your investigation.”
Stated action 3 · response to Kyriacos Athanasis (6 Jan 2023) · stated timescale: 3 February 2023
“the Integrated Care Board (ICB) responsible for JPUH, Norfolk and Waveney ICB, provided a comprehensive response on 3 February 2023 which included information on the improvements being made locally, and details of a serious incident investigation report following Mr [name redacted]' death.”
judiciary.uk/…/2023-0007-Response-from-Department-of-Health-and…
What recurred
- 6 Jan 2023 · Kyriacos Athanasis · Catherine Wood · Closely related · confidence 0.85 (high)
- 18 Dec 2023 · Vivienne Greener · David Pojur · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Kyriacos Athanasis · 6 Jan 2023
“The Emergency department staff gave evidence that they regularly have too many patients in the department and cannot find space to safely allow ambulances to transfer patients into their care and then leave.”
Later · Vivienne Greener · 18 Dec 2023
“There are insufficient doctors and nurses and space available to cope with the number of patients coming into the Emergency Department”
What happened next
No web check of the stated actions has been published for this chain.