Delayed surgery beyond 36 hours
NHS England received 2 coroners' reports about this hazard between 14 Sept 2022 and 22 Nov 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
A published response was found for 1 of the 1 earlier reports, stating 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs [name redacted] case that was not achieved due to a lack of theatre capacity.”
Original on judiciary.uk ↗ NHS England responded, stating 6 specific actions.Response (PDF) ↗
“The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre- pandemic levels”
“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”
4 more stated actions in the Promises tab.
- 1 year 2 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2022 → 2023Kathleen Booth1 year 2 months after Maureen Harrop · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports identify delays in receiving necessary surgery as a risk to patient outcomes. They attribute the delay to insufficient hospital resources such as bed, theatre, or staffing capacity.
Maureen Harrop · 14 Sept 2022
“The evidence at the Inquest was that the NICE guidance promotes surgery within 36 hours. In Mrs [name redacted] case that was not achieved due to a lack of theatre capacity.”
Original on judiciary.uk ↗ Kathleen Booth · 22 Nov 2023
“There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time.”
Original on judiciary.uk ↗
Stated action
“The Trust has now been able to reinstate previous care pathways due to a decline in the national incidence of Covid positive cases. This means that the bed base of trauma and orthopaedics has been increased to near pre- pandemic levels”
Stated action
“The trauma and orthopaedic department run a daily trauma meeting, where all patients with hip fractures who are awaiting surgery are identified. Individual plans of care and management are agreed clinically with the on-call orthopaedic consultant and trauma coordination team. An overview of these patients is also provided to the surgical bed meeting each morning, including the status of each patient and the current wait time for surgery.”
Stated action
“For those patients who can proceed to surgery, this will be scheduled to take place within the 36 hour timeframe to support compliance with NICE guidance. If this is not possible due to a theatre not being available, an urgent review of the entire trauma and elective lists that day will be undertaken. A clinical and operational discussion determines how the patient can be accommodated, and a plan is then devised. The detailed plan is then enacted with the approval of the Divisional Management Team”
Stated action
“The Trust also submits data to the National Hip Fracture Database, which specifically looks at care for patients over the age of 60, who undergo surgery following a hip fracture. This includes data to improve care through quality improvement, in line with NICE guidelines and the National Falls and Fragility Fracture Audit Programme (FFFAP). Data is submitted by the trauma coordinators daily.”
Stated action
“the Trust has implemented a Divisional fractured neck of femur improvement programme, which is reported and monitored daily via the Divisional senior leadership team. Oversight of Divisional compliance with this pathway is also monitored via the Service Quality and Governance Group, which is chaired by the Executive Director of Nursing and Integrated Governance.”
Stated action
“Following the incident, a root cause analysis (RCA) is completed by the trauma coordinators to identify the reasons for the delay and opportunities for learning. The RCA investigations are reviewed weekly in the”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2022 → 2023 | 0.72 | 0.22 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.