Kenneth Clayton
PFD Report
All Responded
Ref: 2025-0094
All 1 response received
· Deadline: 16 Apr 2025
Coroner's Concerns (AI summary)
Prolonged Emergency Department waits in unsuitable environments for high falls-risk patients, driven by ward bed shortages and delayed discharges, highlight inconsistent national falls risk management protocols.
View full coroner's concerns
1. The inquest heard evidence that a key factor in the fall was the prolonged time Mr Clayton was in the Emergency Department waiting for a bed to become available on a ward. The evidence was that he had been in the emergency department for about 8 hours when he fell. The inquest was told that the design of an Emergency Department is not suited to a need for prolonged observation of high falls risk patients. In addition generally patients are cared for on hospital trolleys which cannot be lowered in the way a hospital bed can be which further increases the risk of falls.
2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual. As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.
3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge.
4. The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place. Tameside Hospital had put additional measures in place to manage falls risk in ED in a more consistent way but it was unclear what steps were in place nationally to manage falls risk in a consistent way in Emergency Departments.
2. Prolonged waits in Emergency Department were on the evidence given to the inquest not unusual. As an example the court was told that on the morning the inquest was heard there were patients who had been waiting 40 hours for a bed on a ward.
3. The inquest was told that the primary reason for the challenges in moving patients through the Emergency Department was availability of beds. The evidence given was that the main challenge in freeing up beds was delayed discharge of patients who were medically ready for discharge but who needed a care package or a care home place to facilitate a safe discharge.
4. The inquest was told that for patient safety it was important, that whilst there were delays in ED throughput of patients, that a robust falls risk management system was in place. Tameside Hospital had put additional measures in place to manage falls risk in ED in a more consistent way but it was unclear what steps were in place nationally to manage falls risk in a consistent way in Emergency Departments.
Responses
Action Taken
The DHSC outlines actions Tameside and Glossop Integrated Care NHS Foundation Trust (TGFT) is taking, including implementing an Urgent & Emergency Care Improvement Programme focused on patient flow and discharge; an additional ward opened in November 2024, which includes a discharge lounge. NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. (AI summary)
The DHSC outlines actions Tameside and Glossop Integrated Care NHS Foundation Trust (TGFT) is taking, including implementing an Urgent & Emergency Care Improvement Programme focused on patient flow and discharge; an additional ward opened in November 2024, which includes a discharge lounge. NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems. (AI summary)
View full response
Dear Ms Mutch,
Thank you for the Regulation 28 report of 19 February 2025 sent to the Department of Health and Social Care about the death of Kenneth James Clayton. 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 Clayton’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 regarding Emergency Department waiting times and patient care at Tameside and Glossop Integrated Care NHS Foundation Trust (TGFT). In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
I am assured by NHS England that TGFT is implementing an Urgent & Emergency Care Improvement Programme, which focuses on patient flow and discharge. The programme is entering its second year from April 2025, and significant achievements include:
• There are now 47 patients with a ‘No Criteria to Reside’ status. This is under the trust’s trajectory number of 50, having previously been over 100. This means that patients who are medically fit for discharge are being discharged to the right place much quicker therefore releasing hospital bed capacity.
• An additional ward was opened in November 2024, which includes a discharge lounge. This supports increase in patient flow by caring for those ready for discharge who are waiting for medication and transport.
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-today 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-for-change), 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
• working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework.
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.
Thank you for the Regulation 28 report of 19 February 2025 sent to the Department of Health and Social Care about the death of Kenneth James Clayton. 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 Clayton’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 regarding Emergency Department waiting times and patient care at Tameside and Glossop Integrated Care NHS Foundation Trust (TGFT). In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.
I am assured by NHS England that TGFT is implementing an Urgent & Emergency Care Improvement Programme, which focuses on patient flow and discharge. The programme is entering its second year from April 2025, and significant achievements include:
• There are now 47 patients with a ‘No Criteria to Reside’ status. This is under the trust’s trajectory number of 50, having previously been over 100. This means that patients who are medically fit for discharge are being discharged to the right place much quicker therefore releasing hospital bed capacity.
• An additional ward was opened in November 2024, which includes a discharge lounge. This supports increase in patient flow by caring for those ready for discharge who are waiting for medication and transport.
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-today 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-for-change), 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
• working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework.
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.
Sent To
- Department of Health and Social Care
Response Status
Linked responses
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56-Day Deadline
16 Apr 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 11th September 2024 I commenced an investigation into the death of Kenneth James CLAYTON. The investigation concluded at the end of the inquest on 27th January 2025. The conclusion of the inquest was NARRATIVE: Died from the complications of an unobserved fall that occurred in the Emergency Department during a prolonged wait for an inpatient bed. The medical cause of death was 1a) Bronchopneumonia 1b) Neck of Femur Fracture (operated on) 1c) Fall II) Frailty, Vascular Dementia, Acute Kidney Injury.
Circumstances of the Death
Kenneth James Clayton was taken to Tameside General Hospital after two falls at his home address. He was assessed as requiring inpatient admission to a medical ward. Whilst waiting for an inpatient bed to become available he had an unobserved fall in the Emergency Department. He was found to have fractured his neck of femur and was operated on. Post operatively he deteriorated and developed complications from the fracture and operation. He died at Tameside General Hospital on 23rd August 2024.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.