David Smart

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

08 June 2026 

HM Coroner JOANNE ANDREWS 
Area Coroner for 
West Sussex, Brighton and Hove 

Dear Ms Andrews,  

Thank you for the Regulation 28 report of 22 May sent to the Department of Health and Social Care 
about the death of David John Smart. 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 Mr Smart’s death and 
I  offer  my  sincere  condolences  to  their  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  over  the  continued  use  of  corridors  to  care  for  patients  at  the  Royal 
Sussex Country Hospital Brighton and more widely across the country. 

We recognise the concerns surrounding corridor care and are clear that it is unacceptable and should 
not be allowed to become an accepted part of care delivery. Its presence reflects broader pressures 
across urgent and emergency care, and we are committed to tackling and eliminating it. 

In  considering  your  report,  officials  within  the  Department  of  Health  and  Social  Care  have  made 
enquiries with NHS England and concluded that these concerns are more appropriately addressed 
by NHS England directly. I am advised that NHS England will therefore provide you with a full and 
comprehensive response on the concerns you have raised.   

The Government and NHS England will continue to take action across the full urgent and emergency 
care pathway to improve patient flow, expand available capacity, and reduce avoidable demand on 
accident and emergency departments. This includes focused support for the most challenged trusts, 
alongside  strengthened  reporting  arrangements  and  the  introduction  of  a  consistent  national 
definition  of  corridor  care  to  support  greater  transparency.  We  will  also  begin  publishing  data  on 
corridor care for the first time, subject to assurance of data quality. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Ms Joanne Andrews, 
The Coroner’s Office 
Woodvale 
Lewes Road 
Brighton 
BN2 3QB 

Dear Ms Andrews, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

7 July 2026  

Re: Regulation 28 Report to Prevent Future Deaths – David John Smart who 
died on 14th June 2025.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated  22nd 
May 2026 concerning the death of David John Smart on 14th June 2025. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Mr Smart’s family and loved ones. NHS England is keen to 
assure the family and yourself that the concerns raised about Mr Smart’s care have 
been listened to and reflected upon.   

Your  Report  raises  concerns  that  corridors  are  being  used  to  treat  patients  when 
hospitals have reached capacity across the country. You were concerned that corridor 
care  was  raised  as  a  concern  in  two  Prevention  of  Future  Death  Reports  from 
December 2022 and February 2025 yet the issue continues to be a concern.  

NHS England is clear that corridors are not designated clinical areas and their use for 
patient care is a symptom of significant system pressure rather than planned practice. 

Since  your  previous  Reports to  us,  the  NHS  England  Urgent  and  Emergency  Care 
Plan for 2025/26 has been published (in June 2025) and supported by the Medium-
Term Planning Framework, which sets out a national expectation that systems take 
coordinated  action  to  eliminate  corridor  care  by  improving  end-to-end  patient  flow, 
reducing avoidable hospital congestion and improving timely discharge from hospital. 

Alongside  this,  NHS  England  has  been  and  continues  to  support  providers  and 
Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior 
clinical  decision-making,  increased  use  of  same  day  emergency  care  and  virtual 
wards, and more effective management of patient pathways. The plan also aims to 
reduce demand on emergency departments through improved access to community 
and primary care alternatives  and  strengthened admission  avoidance  pathways,  so 
that patients can be assessed and treated in the most appropriate setting. 

A key element of improving patient flow is reducing delays in discharging patients who 
no longer require acute hospital treatment. Delayed discharges contribute to high bed 
occupancy, reducing capacity for emergency admissions and increasing pressure on 
emergency departments. NHS England is supporting providers and ICBs to strengthen 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 discharge processes, including through the consistent use of criteria-led discharge and 
discharge  to  assess  models.  NHS  England  is  also  developing  “Model  Discharge” 
guidance to support trusts in reducing delays and improving patient flow. 

NHS  England  recognises  that,  despite  these  actions,  corridor  care  is  still  used  in 
exceptional circumstances in some providers when emergency departments are under 
sustained capacity pressure. This is primarily to enable ambulances to be released 
rapidly from hospitals, to address increased risk in the community. This reflects wider 
system flow challenges, including constrained bed capacity, delayed discharges and 
limited community care availability. 

To  strengthen  oversight  and  drive  improvement,  NHS  England  is  working  through 
regional teams to provide targeted support to systems experiencing the highest levels 
of  flow  pressure.  From  May  2026,  the  routine  publication  of  corridor  care  data  has 
begun, increasing transparency and enabling more focused intervention where risks 
to patient safety are greatest. 

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  Mr 
Smart, 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  
NHS England

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT 
FUTURE DEATHS 

Please do not include any living person names in this document, in accordance 

publication policy PDF. 

THIS RESPONSE IS BEING SENT TO: 

The Area Coroner, Joanne Andrews for the Coroner Area West Sussex, 
Brighton and Hove 
REGULATION 28
and an inquest that concluded on 19 May 2026. 

REPORT TO PREVENT FUTURE DEATH 

David John SMART, 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, University Hospitals Sussex NHS Foundation Trust 
provides this response within 56 days of the date of the Report to Prevent 
Future Deaths or any extension granted. 

2. 

DATE OF RESPONSE 

19 June 2026 

3. 

The MATTERS OF CONCERN were identified in the report are as follows: 

During the inquest I heard evidence that at the of Mr Smart's attendance to the 
Emergency Department of the Royal Sussex County Hospital, Brighton that 
there were around 20 patients in the corridor as the Department had reached 
capacity and there was no clinical area available to do so. I understand from 
previous inquests that the area is not designated as a clinical area. 

I have heard in other inquests relating to deaths prior to June 2025 that is 
being taken by University Hospitals Sussex NHS Foundation Trust currently to 
(1) reduce the number of patients who present to the Emergency Department 
who could be seen by other services in the community and (2) to create an 
improved patient flow through the Royal Sussex County Hospital.  

The evidence in this inquest was that, despite these actions, the corridor 
continues to be used when the Emergency Department reaches capacity.  

I was also advised that the use of corridors to care for patients is not only an 
issue at the Royal Sussex County Hospital, Brighton but is used throughout 
the country. 

Prevention of Future Death reports in relation to the use of the corridor for 
patient care was made during investigations into deaths which occurred in 

 
 
 
 
 
 December 2022 and February 2025 and the use of the corridor remains 
ongoing. 

DETAILS OF ACTION TAKEN, how has the concern been addressed. 

4. 

The use of Emergency Department (ED) corridors to care for patients is a 
significant national problem. The Executive team is working closely with very 
senior members of the local ICB (Integrated Care Board), CQC (Care Quality 
Commission), local mental health Trust, and social care providers to tackle the 
problem. As a Trust we cannot solve the problem without all partner 
organisations working together. I am so sorry you have had the need to write to 
us again with your concerns and I too share these concerns.   

The Medicine Divisional Leadership team, the Hospital Directors, and the 
Executive team are continuously working on several separate but linked 
workstreams aiming to eradicate the use of the ED corridor. This is vital for 
patient care to ensure that our patients are treated in the most appropriate 
clinical environment, with dignity, and without delays.  

who are accepted for care directly by the relevant specialty on presentation to 
the ED. We are continually looking to expand the acceptance criteria to ensure 
that we are maximising this process. Additionally, we are directing inter-hospital 
referrals away from the ED and transferring patients directly to the in-patient 
bed base. We have strengthened our Same Day Emergency Care (SDEC) 
medical model from a 7 day a week service to a 24/7 unit where patients can be 
streamed away from the ED and seen and treated on the Acute Medical Unit 
(AMU). These workstreams have all been overseen through the ED Quality 
Oversight Group. The Trust is currently exploring working with a company 
(NEWTON) to increase the opportunity for decompressing the EDs, further 
strengthening the SDECs across the Trust, and improving flow once patients do 
not have a criteria to reside.  

All specialties in-reach to the ED and we operate a 3/2/1 bleep system to 

week. These allow line-by-line reviews of every patient in the corridor to ensure 
all appropriate pathways are considered; this is known as check and challenge 
and provides live escalation. 

The Hospital Alternative Oversight Programme (HALO) is embedded in daily 
practice and continues to be reviewed regularly to ensure all opportunities are 
maximised. This work is aimed at the avoidance of inappropriate hospital 
admissions, to optimise patient flow through the hospital, and smooth discharge 
pathways and processes. This includes:  

 
 
 
 
 
 
   Unscheduled care Navigation Hub 
  Frailty Care Home Outreach & Red Bag Launch 
  Frailty High Weald Lewes & Havens Outreach 

Integrated front door therapies team RSCH (Royal Sussex County Hospital) 
  Virtual Health, both General Virtual Ward and Respiratory Home Monitoring 

Services 

  Frailty and Respiratory SDEC (Same Day Emergency Care) Optimisation 

Interprofessional Standards 

  UTC (Urgent Treatment Centre) Optimisation 
  Early Discharge Planning 
  Deconditioning Prevention 
  Tiered Acuity Model 

These initiatives are in collaboration with our colleagues from the ICB, Sussex 
Community NHS Foundation Trust (SCFT), South East Coast Ambulance 
Service (SECAmb), Sussex Partnership NHS Foundation Trust (SPFT), and 
Brighton & Hove City Council (BHCC).  

There continues to be ongoing collaborative work with the local Mental Health 
Trust, SPFT to ensure that patients requiring mental health hospital admission 
are admitted to an appropriate mental health unit as quickly as possible or avoid 
ED attendance in the first place.  

We continue to use ambulatory space as effectively as possible across the ED 
to maximise clinical space and reduce overcrowding. 

The Continuous Flow Model is embedded within the Medicine Division and 
continues to ensure earlier movement of patients from the Acute Floor and 
reducing the time patients are waiting in the ED for admission to a ward.  There 
are ongoing discussions with clinical Divisions outside the Medicine Division to 
implement a similar model.  

We recognise that the contributory factors leading to corridor care are multi-
faceted and complex. As these issues involve a multi-agency approach, 
working alongside our system partners, we acknowledge that eradicating care 
in non-clinical environments will take considerable time. Therefore, alongside 
these actions, the ED team is continuing to implement local measures to 
improve the quality and safety for patients receiving care in these areas. 
Examples of these are: 

  Digitisation, including electronic observations and prescribing  

Intentional Rounding  

  Fundamental Standards of Care and Corridor standard work 
  Weekly review of high risks 
  Repurposing clinical space to facilitate dedicated space for monitoring 

patients who have been stepped down from the Resuscitation area of ED. 

Our Acute Floor Reconfiguration, which is a £48 million capital improvement 
programme to improve patient and staff experience at the Royal Sussex County 

 
 
 
 
 
 
 
 
 
 
 Hospital, is well underway. The first phase has now been completed with the 
opening of the new Acute Medical Unit and 24/7 Medical SDEC (same day 
emergency care). Phase 2 is scheduled to commence in early 2027. 

5. 

DETAILS OF FURTHER ACTION PROPOSED 

We all agree that corridor care must be stopped both locally and nationally. 
The Trust has made great progress with this and continues to work with the 
ICB and other organisations for their assistance to make sure flow in and out 
of ED is possible so when patients who do not require acute hospital care for a 
physical health condition, they are in appropriate mental health and social care 
environments outside of the acute Trust. 

6. 

SIGNATURE 

Chief Executive 
University Hospitals Sussex NHS Foundation Trust