Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Tamara Davis · 15 Oct 2024 · Joanne Andrews, West Sussex, Brighton and Hove
“privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity.”
judiciary.uk/…/tamara-davis-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Tamara Davis (15 Oct 2024) · stated timescale: none stated
“NHS England is working through the operating model so that NHS England's Regions can support providers to eliminate crowding in Emergency Departments in the longer term.”
Stated action 2 · 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
- 5 Aug 2025 · Maureen Batchelor · Joanne Andrews · Identical hazard · confidence 0.96 (high)
The clearest link, quoted from both reports:
Earlier · Tamara Davis · 15 Oct 2024
“privacy, toilet facilities and confidentiality. I understood from the evidence of the clinicians that they were concerned that patients were being moved into the Corridor but there appeared to be no other option when the Emergency Department exceeds capacity.”
Later · Maureen Batchelor · 5 Aug 2025
“During the inquest I heard evidence from clinicians at University Hospitals Sussex NHS Foundation Trust that 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 1
“The NHS Long Term Plan outlined a commitment to ensuring 70% of Mental Health Liaison services in acute hospitals met the 'Core 24' standard for adults by 2023”
Crowding in Emergency Departments · committees.parliament.uk/writtenevidence/113071/html
“RCEM Acute Insight Series: Crowding and its Consequences [name redacted], Vice President (Policy) [name redacted], Vice President [name redacted], Policy Administrator Pooja Kumari, Policy Manager November 2021 1 Introduction Emergency Department (ED) crowding is a major threat to public health and represents a serious policy challenge that must be urgently tackled”
RCEM Acute Insight Series: Crowding and its Consequences · rcem.ac.uk/…/RCEM_Why_Emergency_Department_Crowding_Matters.pdf
“It is up to the government, NHS leaders, and all of us to work together to put a stop to dangerous crowding; avoidable harm; preventable deaths”
Overcrowding in A&E departments and corridor care is ... · facebook.com/…/1610565563773805
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“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.
No evidence found either way · a stated action in a response
“'Corridor care' is a term used where patients are treated in hospital corridors and other areas that lack the usual facilities for clinical care. Several reports have raised concerns about the s”
General debate on corridor care in the NHS · commonslibrary.parliament.uk/research-briefings/cbp-10938
“'No patient should ever be put through an experience like this': RCP calls for promised national corrido”
‘No patient should ever be put through an experience like this’: RCP calls for promised national corridor care figures to be published as long waits in A&E hit record high | RCP · rcp.ac.uk/…/no-patient-should-ever-be-put-through-an-experience…
No evidence found does not mean the action did not happen.