Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0071, written 4 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2025 |
|---|---|
| Reference | 2025-0071 |
| Deceased | Dorothy Reid |
| Coroner | Catherine Wood |
| Coroner area | North East Kent |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
North East Kent Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: Email: Date: 4 February 2025 Case: REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: State for Health and Social Care and , Chief Executive, NHS England , Secretary of 1. CORONER I am Mrs. Catherine Wood, Assistant Coroner for North East Kent 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 26 April 2024 I commenced an investigation into the death of Dorothy Lilian REID. The investigation concluded at the end of the inquest . The conclusion of the inquest was a Narrative "She died as a consequence of a pulmonary embolism which developed following period of reduced mobility due to a fall where she sustained thoracic and lumbar spinal fractures due in part to her underlying osteoporosis." 1a Massive Bilateral Pulmonary Embolism 1b Deep Vein Thrombosis 1c 1d II Ischaemic Heart Disease, Atherosclerosis 4. CIRCUMSTANCES OF THE DEATH Dorothy Reid was a 91 year old woman who had a medical history of osteoarthritis and osteoporosis as well as anxiety but was independent and living in an annexe of her daughter's home. She fell on 13 March 2024 and was seen in the minor injuries unit where she was assessed and sent home after her head wound was treated. She subsequently contacted her general practitioner who advised her to have an x-ray which was arranged for 21 March 2024. Spinal fractures were identified on the x-ray and she was referred to the emergency department at Queen Elizabeth the Queen Mother (QEQM) hospital and kept overnight before undergoing an MRI scan which confirmed the fractures and advice was sought from the regional neurosurgical department and advice given for her to mobilise and take analgesia. She was seen by an occupational therapist on 26 March 2024 who was concerned about her level of breathlessness and alerted her general practitioner. She was seen by the practice paramedic and gave a history of breathing difficulty after exertion for a few months, worse over the last couple of months and other than breathlessness on exertion she had no signs or symptoms requiring further treatment. On 31 March 2024 her daughter contacted the 111 service and an ambulance attended around 11pm by which time she was complaining of shortness of breath and had bilateral swollen feet and lower legs with no chest pain, but chest tightness after exertion. An ECG revealed widespread T wave inversion and although the ambulance crew advised that she should attend hospital she wanted to avoid a trip to hospital due to her previously having to wait in discomfort for hours and a referral was made to the out of hours general practitioner service instead. She was seen by a general practitioner on 1 April 2024 around 9.30am and gave a history of shortness of breath only on exertion and had bilateral swollen legs although denied chest pain or palpitations and the ECG taken by the paramedics was reviewed and noted. She was assessed and referred for further investigations and given advice to call an ambulance if her symptoms deteriorated. An ambulance was called just after 7pm on 2nd April 2024 and she was taken to Queen Elizabeth the Queen Mother hospital arriving shortly after around 9pm. She was triaged and left to wait in the waiting room as the department was busy. She deteriorated whilst waiting to be seen by a doctor and was transferred from the corridor to the RAT area and seen by a doctor who considered that she was very unwell and transferred her to the resuscitation department where she suffered a cardiac arrest. A return of circulation was achieved and a bedside echocardiogram was suggestive of a pulmonary embolus but it was thought she was unlikely to survive treatment and a decision was made to keep her comfortable and she died shortly after 3.30am on 3 April 2024. A post mortem confirmed a pulmonary embolus was the cause of her death. 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) 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 when she did. Delays in being seen by a doctor at the second attendance were of concern but were found not to be causative of her death. (2) 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. The evidence heard was that on average around 25% of the hospital beds were filled with patients who did not need to be there which in turn leads to patients who need to be admitted not having a bed to be admitted into. This in turn leads to patients waiting in the emergency department for a bed. This places unnecessary pressure on the emergency departments and leads to delays for those seeking emergency treatment. The evidence heard suggested that this was a national not local problem. (3) When asked about whether the delays led to a risk of deaths to others 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. This, in conjunction with the reluctance of patients to attend the emergency department due to long waiting times clearly gives rise to a risk of future deaths unless something is done. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 April 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons her family, East Kent hospitals NHS Trust and The Broadstairs Medical Practice. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 4 February 2025 Signature Catherine Wood Assistant Coroner for North East Kent
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 09 April 2025 Our ref: HM Coroner Catherine Wood North East Kent Coroner’s Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE By email: Dear Mrs Wood, Thank you for the Regulation 28 report of 04 February 2025 sent to the Department of Health and Social Care about the death of Dorothy Lilian Reid. I am replying as the Minister with responsibility for urgent and emergency care. Firstly, I would like to say how saddened I was to read of the circumstances of Ms Reid’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns regarding A&E waiting times, bed capacity and patient experience at Queen Elizabeth and the Queen Mother Hospital and nationally. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. The Government is clear that patients should receive the highest standard of service and care from the NHS. We acknowledge that urgent and emergency care performance has failed to deliver that standard in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. I would like to assure you we are committed to continuing to improve services to ensure patients can access the right care first time, only visiting A&E when necessary, and returning waiting times to the NHS constitutional standard where at least 95% of patients in A&E will be admitted, transferred or discharged within 4 hours. As a first step, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010. We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan- forchange), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future. On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. The planning guidance included 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. 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. • Regarding the concern raised about bed capacity and delays to patient discharge from hospitals, this government will make sure that hospital departments are no longer blocked due to delayed discharges. By developing local partnership working between the NHS and social care, we will ensure we no longer have over 12,000 patients every day waiting to be discharged. We are reforming the Better Care Fund to ensure pooled NHS and local authority funding spent on social care contributes to wider efforts to reduce emergency admissions, delayed discharges, and care home admissions. We will continue to join up health and care services by supporting care workers to safely take on further duties to deliver delegated healthcare activities, such as blood pressure checks and other healthcare interventions, so that people can receive more routine checks and care at home without needing to travel to healthcare settings. Later in the Spring, to accompany the additional investment in the NHS, the Government will publish a 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. In addition, we will shortly set out further actions to be taken during 2025-26 to support improvements to urgent and emergency care performance this year. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
Mrs Catherine Wood
HM Assistant Coroner
North East Kent
Coroner Service Team
Cantium House
Sandling Road
Maidstone
ME14 1XD
Dear Coroner,
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
28 March 2025
Re: Regulation 28 Report to Prevent Future Deaths – Dorothy Lilian Reid who
died on 3 April 2024
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4
February 2025 concerning the death of Dorothy Lilian Reid on 3 April 2024. In advance
of responding to the specific concerns raised in your Report, I would like to express
my deep condolences to Dorothy’s family and loved ones. NHS England are keen to
assure the family and the Coroner that the concerns raised about Dorothy’s care have
been listened to and reflected upon.
Your Report raises concerns over long waits and availability of beds at Emergency
Departments (EDs) and the risks these present to future deaths. You also raised that
beds were being blocked by patients who were medically fit for discharge, along with
the concern that the long waits could deter some patients from attending EDs.
NHS England’s work to improve 4-hour performance
NHS England recognises the significant pressures on all NHS services and, in January
2023, published a two-year Urgent & Emergency Care (UEC) Recovery Plan. The plan
prioritised improvements to the 4 hour standard in Emergency Departments (ED) and
outlined key actions to recover and improve urgent and emergency care services.
Despite significant challenges, including higher than anticipated demand, there has
been a marked improvement in the headline ambition, with over 2.5 million more
people completing their treatment in EDs within 4 hours compared to 2022/23.
NHS England will continue to work through the operating model and assist its Regions
with supporting providers to reduce crowding in EDs. In the longer term, NHS England
hopes to eliminate this by focusing on reducing the number of patients that wait longer
than 12 hours in EDs. Improvements are being demonstrated through NHS England’s
operational planning guidance, where systems were asked to focus on areas to deliver
improved patient flow such as increasing the proportion of patients streamed to
alternative services such as urgent treatment centres (UTCs), same day emergency
care (SDEC) and acute frailty services (AFS). This includes increasing the productivity
of acute and non-acute hospital services, improving flow as well as clinical outcomes.
Improvements to patient discharge
NHS England recognises the significant impact that delayed discharges have on
hospital flow, ambulance handovers and the patients affected by these delays. To
address this, we are strengthening the use of Discharge Ready Date (DRD) and
Reason for Discharge Delay (RfDD) data to gain a clearer understanding of discharge
delays and their key contributing factors, both locally and nationally, so that measures
can be taken to reduce the number of patients occupying beds who are ready for
discharge.
Working with the Department of Health and Social Care (DHSC) and Ministry of
Housing, Communities and Local Government, NHS England has also published the
2025/26 Better Care Fund (BCF) policy framework and planning requirements to
support local systems to jointly agree plans across health and care, including
supporting the flow of patients through urgent and emergency care.
For 2025/26, changes in funding include:
•
•
the NHS minimum contribution to Adult Social Care, which is one of the
mandatory funding streams within the BCF, will increase by 3.9%
the Discharge Fund (£1 billion for 2024/25) that was previously ringfenced has
now been embedded within the NHS minimum contributions to allow systems
greater local flexibility in how they utilise this funding to address flow issues.
Over the coming year we will be working with local areas to support them to maximise
the impact of this investment, for example by providing additional or enhanced support
to those areas which face particular challenges, and working with partners in local
government and social care including the Local Government Association (LGA),
Directors of Social Services (DASSs) and Care and Health Improvement advisors
(CHIAs) to support local systems to improve timely discharge of patients.
Ongoing work to reduce long waits for patients in A&E and for those waiting to
be discharged
NHS England has commenced a data collection of patients experiencing long waits in
Emergency Departments on a daily basis and will ensure actions are in place to
appropriately accommodate these patients as soon as possible. The data is discussed
at the National Coordination Centre call, with actions tracked to ensure executive
oversight and assurance as well as patient safety and harm reviews of/for patients
waiting.
In addition, to reduce the number of very long discharge waits, we have been collecting
weekly data to identify the number of patients waiting over 100 days and will ensure
actions are being taken through system leadership to enable patients to be discharged
to the most appropriate setting as soon as possible. The patients identified as waiting
over 100 days will be discussed at a weekly National Coordination Centre call, and
themes will be tracked through weekly regional engagement meetings.
Regional / Local work to reduce long A&E waits
East Kent have seen a small improvement in the total number of beds being occupied
by patients who longer meet the criteria to reside (‘No Criteria To Reside’), from 17.5%
of beds in April 2024 to 16.9% in January 2025. They are currently in the process of
developing a new plan to reduce their greater than 12 hour waits in the ED.
NHS England’s South East region has undertaken Quality & Safety visits to EDs
across the region to understand the challenges faced in delivering safe and effective
care. This has identified next steps, to include sharing learning and best practice, and
ensuring a quality and safety focus on performance recovery and improvement.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of
Dorothy, are shared across the NHS at both a national and regional level and helps
us to pay close attention to any emerging trends that may require further review and
action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
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