Dorothy Reid
4 Feb 2025 · Coroner Catherine Wood · North East Kent
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. delayed diagnosis of pulmonary embolus
“During the course of the evidence it became clear that on both attendances to the emergency department at QEQM she had to wait on a chair as there were no beds. The first attendance led to such a poor experience that she chose not to go back to hospital when an ambulance was called on 31 March 2024. Had she gone to hospital on 31 March 2024 when advised to do so it is likely that her pulmonary embolus would have been diagnosed in the emergency department and treated and she would not have died”
2. hospital bed blocking causing ED overcrowding
“Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge”
3. risk of future deaths from ED overcrowding
“evidence was brought to the courts attention that the President of the Royal College of Emergency Medicine has published an analysis of the impact that this is having and that there are a significant number deaths associated with long waits in the emergency department”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Further at the time of the inquest there were approximately 140 beds at the Queen Elizabeth Hospital occupied by patients who were medically fit to be discharged, but beds could not be found in the community.”
This report
“Both attendances at the emergency department were on busy shifts but evidence heard from staff was that this was not unusual and the reasons being that beds in the hospital are blocked by patients who are medically fit for discharge.”
Closely relatedConfidence 0.87 · high
This report
“there are a significant number deaths associated with long waits in the emergency department”
Later report
“Such long delays increase the risk of mortality.”
Responses
2025-0071-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · 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.”
2025-0071-Response-from-NHS-England.pdf ↗· NHS England