Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Samuel Garner · 27 Jul 2020 · Alison Mutch, Greater Manchester South
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED.”
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 Tamara Davis (15 Oct 2024) · stated timescale: none stated
“The report raises concerns over emergency department capacity, poor patient flow and the use of corridor care at Royal Sussex County Hospital (RSCH) and nationally. I understand that your report and matters of concerns have also been sent to NHS England, and they are best placed to respond with the specific actions being taken locally to improve urgent and emergency care performance at RSCH.”
What recurred
- 15 Oct 2024 · Tamara Davis · Joanne Andrews · Identical hazard · confidence 0.90 (high)
- 5 Aug 2025 · Maureen Batchelor · Joanne Andrews · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Samuel Garner · 27 Jul 2020
“As a result of the lack of appropriate space Mr [name redacted] an elderly and vulnerable patient was treated in the corridor for periods during his stay in the ED.”
Later · Tamara Davis · 15 Oct 2024
“when the Emergency Department of the Royal Sussex County Hospital, Brighton reached capacity patients would be moved to and treated in the corridor as there was no clinical area available to do so”
What happened next
No evidence found either way · stated action 3
“Several reports have raised concerns about the s”
General debate on corridor care in the NHS · commonslibrary.parliament.uk/research-briefings/cbp-10938
No evidence found does not mean the action did not happen.