Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0335, written 18 Jun 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2026 |
|---|---|
| Reference | 2026-0335 |
| Deceased | Geoffrey Fuller |
| Coroner | Guy Davies |
| Coroner area | Cornwall & the Isles of Scilly |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Information Classification: PUBLIC
HM CORONERS COURT
IN THE MATTER OF THE INQUEST
TOUCHING THE DEATH OF GEOFFREY GORDON FULLER
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
Secretary of State for Health and Social Care
1
CORONER
I am Guy Davies, His Majesty’s Assistant Coroner for Cornwall & the Isles of Scilly.
2
DATE OF REPORT
18 June 2026
3
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.
4
THIS REPORT IS BEING SENT TO
1. The deceased Mr Fuller’s family
2. The Chief Coroner for England and Wales
3. Royal Cornwall Hospital Trust (RCHT)
4. South West Ambulance Service Trust (SWAST)
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 13 August 2026. I, the coroner, may extend the period if an appropriate
application is made.
5
YOUR RESPONSE
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.
I have a duty to send a copy of your response to the Chief Coroner.
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Information Classification: PUBLIC
In accordance with the Chief Coroner’s Publication Policy, you should send me any
representations regarding publication of your response. These representations should be
made at the same time as the response is provided. I will pass any representations
received to the Chief Coroner for a decision.
Please note any links to webpages included in the response will not be checked for
sensitive information prior to publication, as the information is already online.
The names of those who do not respond to PFD reports are regularly published on the
Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports -
Courts and Tribunals Judiciary.
6
SUMMARY OF CORONER’S CONCERN
(1) Insufficient social care provision leading to large numbers of patients in hospital
who are otherwise fit for discharge, thereby impeding patient flow through hospital,
there being a direct link between inadequate social care provision and ambulance
delays.
(2) Significant handover delays at RCHT and other southwest hospitals leading to
ambulance resources being tied up with increased response delays and increased
mortality risks for patients in the community waiting for emergency ambulances.
(3) ED crowding leading to increased risk in mortality for patients being held in
ambulances and corridors and being delayed from receiving surgery or specialist
treatment on wards.
7
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you [AND/OR
your organisation] have the power to take such action.
8
INVESTIGATION and INQUEST
On 14 July 2026 I commenced an investigation into the death of 91-year-old Geoffrey
Gordon Fuller. The investigation concluded at the end of the inquest on 8 June 2026.
The medical cause of death was established on the evidence as follows:
1a Ruptured Abdominal Aortic Aneurysm
II Ischaemic Heart Disease
The four questions - who, when, where and how – were answered as follows:
Geoffrey Gordon FULLER died on 8 July 2025 at Royal Cornwall Hospital Treliske
Truro from a ruptured Abdominal Aortic Aneurysm
My conclusion as to the death was as follows:
Natural causes
9
CIRCUMSTANCES OF THE DEATH
Mr Fuller called for an ambulance due to a dislocated hip. There followed a 13-hour
ambulance delay during which time 91-year-old Mr Fuller had to endure unnecessary pain
and suffering. During his subsequent admission Mr Fuller died of a condition unrelated to
the dislocated hip, namely a ruptured aneurysm.
The ambulance delay did not more than minimally contribute to the ruptured aneurysm.
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Information Classification: PUBLIC
10 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. –
Significant handover delays
1. The court noted that the NHS national target is for ambulances to handover
patients to hospital is within 15 minutes of arrival.
2. The total ambulance delay on 7 July 2025 for Mr Fuller was approximately 13
hours, involving delays in both response and handover.
3. The delay in ambulance response was 10 hours and 12 minutes, during which time
Mr Fuller was in pain and unable to move due to a dislocated hip.
4. On arrival at Royal Cornwall Hospital (RCHT), Mr Fuller spent a further 2 hours
and 52 minutes before being handed over to the emergency department.
5. On 7 July 2025, at RCHT, the average handover time was two hours, 24 minutes
with over 211 hours of ambulance availability lost to these handover delays. This
is the equivalent of approximately 19 double crewed ambulance (DCA) shifts lost
to delays (based on a standard 11-hour shift).
6. Data for the two months before Mr Fuller’s death reveals average handover delays
at RCHT of 1 hour and 26 minutes for May 2025, and 1 hour and 27 minutes for
June 2025 (beyond the 15 minute target).
7. Recent data indicates the picture has not improved. Significant average handover
delays at RCHT were recorded for every month of 2026 to date (beyond the target
15 minutes). The data for May 2026 indicates an average handover delay of 1 hour
and 22 minutes beyond the 15-minute target.
8. The day before this Inquest, 7 June 2026, SWAST recorded average handover
delays at RCHT of 1 hour and 10 minutes.
9. These handover delays lead to the unavailability of ambulances to respond to
emergency calls. Furthermore, the average handover delays conceal spikes such
as that which led to the long delay in this case. Such long delays increase the risk
of mortality.
10. The court heard evidence of a new policy being implemented by SWAST to try and
reduce ambulance resources being tied down in lengthy waits at hospital. After a
90-minute handover delay the ambulance paramedics will provide notice to ED that
a patient is being left on a trolley in a corridor with fluids and medications if
required so long as that patient is stable. This has led to significant crowding in
RCHT emergency department (ED).
Emergency department crowding
1. On the day of Mr Fuller’s ambulance delay, RCHT ED was accommodating 105
patients. ED has a capacity of 42 patients. ED accommodated the surplus
patients on trolleys in corridors, seated within the waiting room or remaining inside
ambulances in the parking area outside ED.
2. The situation had not improved as at the date of this Inquest.
3. EDs have a national target for 95% of patients to be admitted, transferred or
discharged within 4 hours. It was noted that there is a recent major study which
shows that the standardised mortality rate starts to rise from 5 hours after the
patient’s time of arrival at the ED and they concluded that after 6–8 hours, there is
one extra death for every 82 patients delayed. This increased mortality is partly
attributed to the fact that patients in ED are not receiving the surgery or specialist
care that is available on the wards.
4. Data indicates that RCHT have been failing to meet the 4-hour target for a
significant number of patients. For the opening months of 2026 approximately
50% of patients have still been in ED after 4 hours.
5. RCHT witnesses reported that over the last few weeks the ED has been regularly
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Information Classification: PUBLIC
required to accommodate over 100 patients (in a unit with a capacity for 42
patients). This has involved significant numbers of patients still in ED after 12
hours, some still in ED after 24 hours.
Insufficient social care provision
1. The court found there was insufficient bed availability on acute wards which was
attributable to significant numbers of patients in hospital with no reason to reside
(NCTR), these being patients who are medically optimised but cannot be
discharged due to lack of onward care support.
2. On the day of the ambulance delay, 7 July 2025, almost 20% of patients in RCHT
were recorded as NCTR.
3. The court noted the main cause for the numbers of NCTR patients was insufficient
4.
social care provision, whether commissioned by social services or NHS.
Investigations in 2022 and 2023 by SWAST and the Healthcare Safety
Investigation Branch (HSIB) found a direct link between ambulance delays and
inadequate social care provision. The court noted the SWAST systems report
which found…
‘’….there is a direct link between patients waiting in the hospital for
discharge to social care and patients being cared for inside ambulances
and Emergency Departments.’’
5.
This court has previously noted data indicating significant vacancies in social care
posts in Cornwall are vacant reflecting the national picture of nationwide vacant
direct social care posts. [see previous PFD reports on this subject]
6. The court noted that the NHS does not carry responsibility for the recruitment and
retention of social care staff or any broad obligation to promote the social care
market.
7. The HSSIB report referred to the fact that the organisations immediately required
to deal with ambulance delays are ambulance trusts and acute hospitals, In
Cornwall that is SWAST and RCHT. These organisations do not have control over
the services primarily responsible for ambulance delays, namely social care
provision and support. They are unable to influence the whole-system and
therefore carry risks that they cannot wholly mitigate or manage.
8. The court noted the HSSIB report which states that delayed discharges (and
consequent ambulance delays) are a national issue which is attributed to a whole
system failure of health and social care. The court noted the HSSIB investigation’s
first safety recommendation is an urgent ‘whole system’ response to reduce patient
harm.
11 COPIES AND PUBLICATION OF THIS REPORT
I have a duty to send a copy of my report to every Interested Person who in my opinion
should receive it.
I also may send a copy of the report to any other person who I believe may find it useful or
of interest.
I can confirm I have sent the report to Mr Fuller’s family.
I also have a duty to send a copy of the report to the Chief Coroner.
You may make representations to me, the coroner, about the publication of the contents of
this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations
will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for
additional information relating to the publication of reports and responses.
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Information Classification: PUBLIC
SIGNATURE
HMC Guy Davies
5
1 response 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 Public Health and Patient Safety 39 Victoria Street London SW1H 0EU HM Assistant Coroner Guy Davies Cornwall Coroner’s Service Pydar House Pydar Street Truro Cornwall TR1 1XU Dear Mr Davies, 17 August 2026 Thank you for the Regulation 28 report of 18 June 2026 sent to the Secretary of State of Health and Social Care about the death of Geoffrey Gordon Fuller. I am replying as the Minister of State for Public Health and Patient Safety at the Department of Health and Social Care. Firstly, I would like to say how saddened I was to read of the circumstances of Geoffrey Gordon Fuller’s death, and I offer my sincere condolences to his 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 insufficient social care provision leading to large numbers of patients at Royal Cornwall Hospital Trust who are otherwise fit for discharge, thereby impeding patient flow through hospital. This is linked to greater crowding in Emergency Departments, and longer ambulance handover delays, and in turn to increased mortality risks for those patients held in corridors and in ambulances being delayed from receiving surgery or specialist treatment on wards. The Government recognises and shares your concerns regarding the impact that delays in accessing appropriate social care and community support can have on patient outcomes. Timely discharge relies on effective joint working between the NHS, local authorities and social care providers. The Government continues to support local systems to improve integration between health and social care through the Better Care Fund (BCF). For 2026/27, over £9 billion is committed through the BCF, with integrated care boards and local authorities required to jointly plan and deliver services that help people maintain or regain their independence, prevent avoidable admissions, and support timely and effective discharge from hospital. Recent reforms to the BCF place greater emphasis on rehabilitation, reablement and other recovery-focused services, reflecting the importance of coordinated support in reducing delays and improving patient outcomes. Beyond these immediate measures, this Government’s vision for a National Care Service is about building a social care system that gives people greater choice, control, dignity and independence. The Prime Minister has made clear that he wants to see rapid progress on this, working in partnership with the adult social care sector. The Government is driving progress on the recommendations that Baroness Casey’s independent commission into adult social care made earlier this year for immediate action on dementia, motor neurone disease and adult safeguarding. The Government has also brought forward the date for Baroness Casey’s commission to make recommendations on the future of adult social care and how to deliver the National Care Service; the Commission will now report by summer 2027 rather than by 2028. The Commission remains central to the Government’s ambition to reform adult social care. The Big Conversation on Care, launched by Baroness Casey on 29 July, is a key next step, giving people across England the opportunity to say what they want and expect from a future National Care Service. We also recognise your concerns regarding ambulance handover delays and emergency department crowding. The Medium Term Planning Framework sets out NHS England’s expectations for how local systems should plan and deliver services over the coming years, supporting recovery, improved performance, financial sustainability and better outcomes for patients. The national standard for hospital handovers remains 15 minutes, and the framework makes clear that handovers should not exceed 45 minutes. NHS England continues to work with ambulance services, acute trusts, integrated care boards and wider partners to improve patient flow, reduce handover delays and ensure patients receive timely assessment, treatment and transfer to the most appropriate care setting. This includes, through delivering the Urgent and Emergency Care Delivery Plan 2025/26, having invested over £450 million to expand urgent and emergency care capacity. We have also published national clinical standards through the Model Emergency Department, Model Acute Pathway and Model Discharge programmes, which are designed to improve flow through hospitals, reduce prolonged waits and support safer emergency care. NHS England is also deploying Getting It Right First Time clinical improvement teams to provide targeted support to trusts experiencing the greatest urgent and emergency care pressures, including where corridor care is prevalent. These teams work with local systems to identify barriers to patient flow and implement evidence-based improvements to improve patient safety and reduce prolonged waits. We note your findings regarding the whole-system nature of these issues and will carefully consider this report alongside wider evidence on discharge delays, patient flow and urgent and emergency care pressures. The Government remains committed to working with partners across the health and care system to improve discharge arrangements, strengthen integration between services and ensure patients receive safe, timely and appropriate care. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR PUBLIC HEALTH AND PATIENT SAFETY
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