Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Mohan Acharya · 27 Feb 2020 · Hassan Shah, Northampton
“Emergency department crowding is associated with increased mortality amongst admitted patients;”
judiciary.uk/prevention-of-future-death-reports/mohan-acharya
What was promised
Stated action 1 · response to Lyn Brind (18 Jan 2023) · stated timescale: across this fiscal year
“also plan also commits to reducing average Category 2 ambulance response times to 30 minutes across this fiscal year.”
judiciary.uk/…/2023-0017-Response-from-Department-of-Health-and…
Stated action 2 · response to Dorothy Reid (4 Feb 2025) · stated timescale: 2025/26
“The NHS will focus on delivering the following range of practical actions to improve performance in 2025/26: - increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care (SDEC) - optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres (UTCs) - increasing the percentage of patients discharged by or on day 7 of their admission.”
Stated action 3 · response to Andrew Waters (3 Apr 2025) · stated timescale: March 2026
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
What recurred
- 18 Jan 2023 · Lyn Brind · Jacqueline Lake · Closely related · confidence 0.90 (high)
- 4 Feb 2025 · Dorothy Reid · Catherine Wood
- 3 Apr 2025 · Andrew Waters · Guy Davies · Closely related · confidence 0.90 (high)
- 18 Jun 2026 · Geoffrey Fuller · Guy Davies · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Mohan Acharya · 27 Feb 2020
“Emergency department crowding is associated with increased mortality amongst admitted patients;”
Later · Geoffrey Fuller · 18 Jun 2026
“On the day of Mr [name redacted] ambulance delay, RCHT ED was accommodating 105 patients. ED has a capacity of 42 patients.”
What happened next
No evidence found either way · stated action 1
“our site work. We'd like to use additional cookies to understand how you use the site and improve our services. You”
Ambulance service response times · commonslibrary.parliament.uk/research-briefings/cdp-2025-0042
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“Same Day Emergency Care (SDEC) is a healthcare approach allowing specialists to assess, diagnose, and treat patients on the same day they arrive at the hospital. It is designed as a substitute for traditional hospital admission, aiming to address certain urgent health conditions efficiently without requiring overnight stays.”
How Same Day Emergency Care Can Prevent More Serious Issues - davidmmayerdmd.com · davidmmayerdmd.com/…/how-same-day-emergency-care-can-prevent-mo…
“Same day emergency care (SDEC) describes an ambulatory service designed to provide an alternative to ED management, reduce admission rates and improve emergency care system performance.”
Impact of same day emergency care services on urgent and emergency care delivery outcomes: a systematic review · pmc.ncbi.nlm.nih.gov/articles/PMC12505097
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
“Hospitals in England should create "extended emergency medicine ambulatory care" (EEMAC) areas to accommodate patients facing longer waits who can be safely investigated and managed during a prolonged emergency department stay, according to new guidance from NHS”
NHS Backs New A&E Care Areas for Patients Facing Long Waits · medscape.com/…/nhs-backs-new-a-e-care-areas-patients-facing-lon…
No evidence found does not mean the action did not happen.