Kathleen Ward
PFD Report
All Responded
Ref: 2025-0562
All 1 response received
· Deadline: 29 Dec 2025
Coroner's Concerns (AI summary)
The emergency department faces persistent overcrowding with patients awaiting ward beds, leading to delays in appropriate emergency care and risking repeat incidents due to insufficient bed capacity.
View full coroner's concerns
1. During the evidence it was heard that the emergency department still has people being held in their department who should be getting ward based care. Additionally, that there has been no increase in the bed space available for Queens Centre. This meant that I could have no reassurance that the circumstances of Mrs Ward’s death would not be repeated, but also that people requiring emergency treatment may be delayed in receiving the appropriate emergency care.
Responses
Action Taken
The Trust is strengthening escalation processes for patients approaching end of life, reinforcing expectations around compassionate communication, continuing work on bed modelling and discharge processes, ensuring feedback informs staff education, and rolling out Comfort Observations across the organisation. (AI summary)
The Trust is strengthening escalation processes for patients approaching end of life, reinforcing expectations around compassionate communication, continuing work on bed modelling and discharge processes, ensuring feedback informs staff education, and rolling out Comfort Observations across the organisation. (AI summary)
View full response
Dear Ms Harris
Re: Regulation 28 Report – Death of Mrs Kathleen Rose Ward
Thank you for your Regulation 28 Report dated 3 November 2025. On behalf of Hull University Teaching Hospitals NHS Trust, I offer our sincere condolences to Mrs Ward’s family for their loss. We welcome the opportunity to respond to the important concerns you have raised regarding access to specialist beds at the Queen’s Centre and the impact this had on patient flow and Emergency Department (ED) pressures.
The Trust takes the matters identified extremely seriously. We fully recognise the distress experienced by Mrs Ward’s family and acknowledge that the Emergency Department is not the appropriate environment for patients requiring specialist palliative or end-of-life care.
1. Commissioning and Bed Capacity at the Queen’s Centre
The Queen’s Centre provides commissioned specialist oncology and haematology beds, primarily for:
• patients receiving active cancer treatment,
• patients requiring admission for complications or toxicities of treatment,
• acute haematology patients requiring specialist support.
The Centre does not have a separately commissioned palliative care bed base. However, due to the nature of our patient population, many patients approaching end of life are cared for within these existing specialist beds.
The Trust cannot unilaterally increase the permanent bed base for this service. Capacity is set through specialised commissioning arrangements with NHS England and the Integrated Care Board (ICB), including workforce, funding, and estate constraints. We continue to work closely with commissioners to review demand modelling and future requirements for cancer and supportive care capacity.
As reflected in the evidence heard at inquest, no bed was available at the Queen’s Centre at the time of Mrs Ward’s presentation, resulting in her assessment in the the ED.
This reflects capacity constraints within a fixed specialist service rather than a failure to recognise the appropriateness of ward-based end-of-life care.
23 December 2025 Hull Royal Infirmary Anlaby Road Hull HU3 2JZ
Ms Lorraine Marks East Riding and Hull Coroner Service The Guildhall, Alfred Gelder Street,
2. Emergency Department Environment
The Trust recognises and accepts the Coroner’s concern that the Emergency Department is not designed to deliver specialist palliative or end-of-life care. ED staff are trained and resourced to manage acute, life- threatening conditions, and the environment presents inherent challenges in relation to:
• privacy and dignity,
• access to specialist palliative medications,
• timely symptom control, and
• coordination across multiple clinical teams.
3. Patient Flow, Discharge Capacity and ED Pressures
We acknowledge the Coroner’s concern that patients who require ward-based or palliative care are sometimes held in the ED when no beds are available. This is deeply regrettable and not the standard of care we wish to provide.
The challenges described are linked to system-wide flow issues, which are recognised nationally. The Government’s Hospital Discharge and Community Support Guidance (2024) states that:
• hospital discharge and community support are joint responsibilities of NHS bodies and local authorities,
• acute bed flow depends on timely access to social care packages, community support and intermediate care,
• systems must work within “the budgets available to NHS commissioners and local authorities”.
As with many hospitals nationally, delayed discharges caused by waits for community care or social care provision reduce the number of available acute and specialist beds, including oncology and palliative beds. This can result in patients being admitted via the ED when they ideally should go directly to a specialty ward.
The Trust is undertaking ongoing initiatives to bed model, review processes to maximise discharges, and work with community partners to support patients who require social care. These actions are consistent with national guidance and aim to improve flow through the acute bed base, including specialist oncology beds.
4. Actions Taken Following Mrs Ward’s Death
Internal review, complaints investigation and clinical reflection have resulted in the following actions:
• Review of decision-making and communication processes within Ward 32 (Queen’s Centre) to identify learning relating to recognition of deterioration and end-of-life planning.
• Emergency Department learning focused on communication, compassion, escalation and coordination of care for patients approaching end of life.
• The development of comfort observations which focus on monitoring symptoms that affects a patient’s comfort using specific scales to ensure timely interventions and support for people in their final days of life.
• Sharing of learning at governance forums within Emergency Medicine, Oncology and Acute Medicine to inform service improvement.
• Quality Improvement project commenced to develop an early identification tool, combining the frailty score, ‘and Gold Standard Framework for early care planning.
The complaint response also acknowledges that delays in pain management and coordination of care in the Emergency Department were unacceptable, and that learning from this case is being used to improve future practice.
5. Actions to Reduce the Risk of Recurrence
Drawing on the learning from this case and in line with national guidance, the Trust has taken and is continuing to take the following actions:
• Strengthening escalation processes to ensure earlier senior clinical review when patients approaching end of life present to hospital.
• Reinforcing expectations around compassionate communication and dignity in end-of-life care.
• Continuing work on bed modelling and discharge processes to improve flow through specialist and acute beds.
• Ensuring that feedback from this case informs ongoing staff education and governance discussions, particularly within the Emergency Department and Acute Medicine.
• Further roll out of Comfort Observations across the organisation to include the Emergency Department.
• To pilot the Identification Tool in Ward 32 and further roll out of the tool across the organisation.
Conclusion
We fully accept the Coroner’s concern that the circumstances experienced by Mrs Ward and her family were unacceptable, and we are committed to ensuring that patients approaching the end of life receive care that is dignified, compassionate, and in an appropriate environment.
While specialist bed capacity is determined through commissioning arrangements and whole-system discharge capacity, the Trust recognises its responsibility to act wherever it can within its remit. We believe the actions outlined above will significantly reduce the risk of recurrence, and we will continue to work with system partners to address the wider structural challenges that contribute to bed availability and flow pressures.
Please do not hesitate to contact me should you require any further information.
Re: Regulation 28 Report – Death of Mrs Kathleen Rose Ward
Thank you for your Regulation 28 Report dated 3 November 2025. On behalf of Hull University Teaching Hospitals NHS Trust, I offer our sincere condolences to Mrs Ward’s family for their loss. We welcome the opportunity to respond to the important concerns you have raised regarding access to specialist beds at the Queen’s Centre and the impact this had on patient flow and Emergency Department (ED) pressures.
The Trust takes the matters identified extremely seriously. We fully recognise the distress experienced by Mrs Ward’s family and acknowledge that the Emergency Department is not the appropriate environment for patients requiring specialist palliative or end-of-life care.
1. Commissioning and Bed Capacity at the Queen’s Centre
The Queen’s Centre provides commissioned specialist oncology and haematology beds, primarily for:
• patients receiving active cancer treatment,
• patients requiring admission for complications or toxicities of treatment,
• acute haematology patients requiring specialist support.
The Centre does not have a separately commissioned palliative care bed base. However, due to the nature of our patient population, many patients approaching end of life are cared for within these existing specialist beds.
The Trust cannot unilaterally increase the permanent bed base for this service. Capacity is set through specialised commissioning arrangements with NHS England and the Integrated Care Board (ICB), including workforce, funding, and estate constraints. We continue to work closely with commissioners to review demand modelling and future requirements for cancer and supportive care capacity.
As reflected in the evidence heard at inquest, no bed was available at the Queen’s Centre at the time of Mrs Ward’s presentation, resulting in her assessment in the the ED.
This reflects capacity constraints within a fixed specialist service rather than a failure to recognise the appropriateness of ward-based end-of-life care.
23 December 2025 Hull Royal Infirmary Anlaby Road Hull HU3 2JZ
Ms Lorraine Marks East Riding and Hull Coroner Service The Guildhall, Alfred Gelder Street,
2. Emergency Department Environment
The Trust recognises and accepts the Coroner’s concern that the Emergency Department is not designed to deliver specialist palliative or end-of-life care. ED staff are trained and resourced to manage acute, life- threatening conditions, and the environment presents inherent challenges in relation to:
• privacy and dignity,
• access to specialist palliative medications,
• timely symptom control, and
• coordination across multiple clinical teams.
3. Patient Flow, Discharge Capacity and ED Pressures
We acknowledge the Coroner’s concern that patients who require ward-based or palliative care are sometimes held in the ED when no beds are available. This is deeply regrettable and not the standard of care we wish to provide.
The challenges described are linked to system-wide flow issues, which are recognised nationally. The Government’s Hospital Discharge and Community Support Guidance (2024) states that:
• hospital discharge and community support are joint responsibilities of NHS bodies and local authorities,
• acute bed flow depends on timely access to social care packages, community support and intermediate care,
• systems must work within “the budgets available to NHS commissioners and local authorities”.
As with many hospitals nationally, delayed discharges caused by waits for community care or social care provision reduce the number of available acute and specialist beds, including oncology and palliative beds. This can result in patients being admitted via the ED when they ideally should go directly to a specialty ward.
The Trust is undertaking ongoing initiatives to bed model, review processes to maximise discharges, and work with community partners to support patients who require social care. These actions are consistent with national guidance and aim to improve flow through the acute bed base, including specialist oncology beds.
4. Actions Taken Following Mrs Ward’s Death
Internal review, complaints investigation and clinical reflection have resulted in the following actions:
• Review of decision-making and communication processes within Ward 32 (Queen’s Centre) to identify learning relating to recognition of deterioration and end-of-life planning.
• Emergency Department learning focused on communication, compassion, escalation and coordination of care for patients approaching end of life.
• The development of comfort observations which focus on monitoring symptoms that affects a patient’s comfort using specific scales to ensure timely interventions and support for people in their final days of life.
• Sharing of learning at governance forums within Emergency Medicine, Oncology and Acute Medicine to inform service improvement.
• Quality Improvement project commenced to develop an early identification tool, combining the frailty score, ‘and Gold Standard Framework for early care planning.
The complaint response also acknowledges that delays in pain management and coordination of care in the Emergency Department were unacceptable, and that learning from this case is being used to improve future practice.
5. Actions to Reduce the Risk of Recurrence
Drawing on the learning from this case and in line with national guidance, the Trust has taken and is continuing to take the following actions:
• Strengthening escalation processes to ensure earlier senior clinical review when patients approaching end of life present to hospital.
• Reinforcing expectations around compassionate communication and dignity in end-of-life care.
• Continuing work on bed modelling and discharge processes to improve flow through specialist and acute beds.
• Ensuring that feedback from this case informs ongoing staff education and governance discussions, particularly within the Emergency Department and Acute Medicine.
• Further roll out of Comfort Observations across the organisation to include the Emergency Department.
• To pilot the Identification Tool in Ward 32 and further roll out of the tool across the organisation.
Conclusion
We fully accept the Coroner’s concern that the circumstances experienced by Mrs Ward and her family were unacceptable, and we are committed to ensuring that patients approaching the end of life receive care that is dignified, compassionate, and in an appropriate environment.
While specialist bed capacity is determined through commissioning arrangements and whole-system discharge capacity, the Trust recognises its responsibility to act wherever it can within its remit. We believe the actions outlined above will significantly reduce the risk of recurrence, and we will continue to work with system partners to address the wider structural challenges that contribute to bed availability and flow pressures.
Please do not hesitate to contact me should you require any further information.
Sent To
- Chief Executive – Hull Royal Infirmary
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Dec 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 3rd March 2025 I commenced an investigation into the death of Kathleen Rose WARD, aged 76 years. An inquest was opened on 7th March 2025 and the investigation concluded at the end of the inquest on 3rd November 2025. The conclusion of the inquest was: NARRATIVE: Natural causes contributed to by industrial disease The following findings of fact were made: Mrs WARD diagnosed with malignant mesothelioma in October 2022 following a biopsy. Mrs WARD had exposure to asbestos both via her own working life but also by washing her husband’s clothes which were covered in dust (he detailed working with asbestos). Evidence was heard of freely circulating asbestos fibres both of those scenarios. When gravely ill, on 19th February 2025 there were no available beds at the Queens Centre which would be appropriately equipped to deal with patients at end of life. Mrs Ward therefore had to be taken to the emergency department at Hull Royal Infirmary. For 21 hours there were no suitable beds available. It is expected that a suitable bed should be found within 4 hours. This meant that Mrs Ward was in a location that did not have the specialism, the medication, or the privacy to care for her in her final hours. The lack of understanding lead to issues over appropriate pain relief being administered to Mrs Ward in a timely manner. At a time that it was evident to the family that Mrs Ward was approaching end of life, she was moved unnecessarily from a quiet room to a 6-bay location, she died very shortly afterwards. I can only echo the words of a nurse, it was not acceptable or dignified. I have heard that where beds are not available at Queens Centre, patients are taken to the Emergency Department. Since Mrs Ward’s death I have heard that although some processes are in place to try to prevent patients on palliative care being taken to the Emergency Department (bed modelling and capacity), it still occurs at least once a week, and that there has been no increase in the bed space available at the Queens Centre. Beds at Queen Centre treat both those with life limiting conditions, on palliative care and those on end of life care. The lack of bed space means that people are still being treated in unsuitable environments, by staff who do not have a specialism in palliative care and medical pain relief required at end of life. This also means those with life limiting illnesses will not be treated appropriately to alleviate symptoms before end of life to prolong and give pain free/limiting treatment. Space being taken up in the Emergency Department also means that those requiring life saving emergency treatment may be delayed in receiving appropriate care. RPFD. Box 3 of the record of inquest read: Kathleen Rose Ward, aged 76 years, died from pneumonia at Hull Royal Infirmary on 20th February 2025. Mesothelioma, Immunotherapy induced myocarditis and chronic kidney disease contributed to her demise. Mrs Ward suffered breathlessness in April 2021, underwent a biopsy in September 2022 and was diagnosed with malignant mesothelioma in October 2022. Evidence was heard that she was exposed to freely circulating asbestos fibres during her own working life but also when she washed her husband’s overalls throughout a period of time when he reported working with asbestos. Her medical cause of death was recorded as: 1a Pneumonia Mesothelioma, Immunotherapy induced myocarditis, chronic kidney disease
Circumstances of the Death
Mrs Kathleen Rose WARD had been diagnosed with terminal mesothelioma. On 19th February 2025 she was admitted to the emergency department at Hull Royal Infirmary as no beds were available at Queens Centre. Queens Centre would have been a place where Mrs WARD would have received appropriate care and medications for end of life. Due to the lack of bed space, Mrs WARD remained in the emergency department - a location where staff are trained to try to save life rather than deal with chronic illness and end of life care. Mrs WARD had no dedicated specialist care, inappropriate pain relief and encountered treatment, that although not within the HM remit, was acknowledged by the hospital to be unacceptable. I noted that other issues were to be taken up directly by the hospital and do not form part of this report.
Copies Sent To
(Hull City Council, Hull University, Frederick Singleton (ceased trading))
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve LAS procedures for timing and recording ambulance whereabouts
Fennell Inquiry
Ambulance Handover Delays
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.