Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate patient handover practices
The earlier warning
Rebecca Evans · 14 Mar 2017 · John Gittins, North Wales (East and Central)
“current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
judiciary.uk/prevention-of-future-death-reports/rebecca-evans
What was promised
Stated action 1 · response to Rebecca Evans (14 Mar 2017) · stated timescale: none stated
“The plan addresses the main causes of Unscheduled Care pressure through reducing admissions (demand), reducing DTOCs and length of stay (supply) and addressing flow at the front of hospitals to protect minors from long waits. It also includes reducing ambulance handover delays.”
judiciary.uk/…/2017-0077-Response-by-University-Health-Board.pdf
What recurred
- 20 Feb 2023 · David Strachan · Kate Sutherland · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Rebecca Evans · 14 Mar 2017
“current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for long periods in ambulances”
Later · David Strachan · 20 Feb 2023
“there were significant handover delays across all BCUHB sites.”
What happened next
No web check of the stated actions has been published for this chain.