Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Lauren Bridges (1) · 19 Sept 2023 · Andrew Bridgman, Manchester South
“This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider's hospital has been a contributory factor in that patient's death.”
judiciary.uk/…/lauren-bridges-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Lauren Bridges (1) (19 Sept 2023) · stated timescale: 2023/24
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
Stated action 2 · response to Lauren Bridges (1) (19 Sept 2023) · stated timescale: none stated
“The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.”
judiciary.uk/…/2023-0438-Response-from-Dorset-Healthcare-Univer…
Stated action 3 · response to Lauren Bridges (1) (19 Sept 2023) · stated timescale: none stated
“We have enhanced the daily Hospital Overview situation report which is accurate at the point it is sent, with the purpose of providing a summary at the start of the working day across the organisation to key colleagues including senior clinicians and managers.”
judiciary.uk/…/2023-0438-Response-from-Dorset-Healthcare-Univer…
4 further stated actions are listed on the full chain page.
What recurred
- 14 Jun 2024 · Amina Ismail · Andrew Bridgman · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Lauren Bridges (1) · 19 Sept 2023
“This is the second inquest I have heard where the delayed discharge/repatriation of an Out-of-Area patient from an independent provider's hospital has been a contributory factor in that patient's death.”
Later · Amina Ismail · 14 Jun 2024
“delayed transfer of an out-of-area patient from an independent provider's hospital has been a contributory factor in that patient's death”
What happened next
No evidence found either way · stated action 1
“We will support local decision making, empowering local leaders to make the best decisions for their local populations and have set out fewer, more focused national objective”
2023/24 priorities and operational planning guidance · england.nhs.uk/…/PRN00021-23-24-priorities-and-operational-plan…
No evidence found does not mean the action did not happen.