Over the course of the inquest, the court heard evidence to the effect that:
1. Despite the seriousness of her condition, Mrs Moss waited over 5 hours from arrival at the Emergency Department until she was fully assessed by a doctor;
2. Mrs Moss waited for around 19 hours in the Emergency Department before a bed was to become available for her on the Acute Medical Unit;
3. Across both units, there were a number of missed opportunities to recognise a deterioration in Mrs Moss’s condition. The court heard as to a number of steps the Trust has taken locally to reduce risk to patients including increasing initiation of treatment prior to medical review, and making plans to expand the footprint of the Emergency Department. Notwithstanding such measures, it is a matter of residual concern that systemic problems within the health and social care sectors including difficulty in accessing primary care and delayed discharges combine to lead to persistently high levels of demand on hospital Emergency Departments. Such sustained demand makes timely and effective monitoring of a patient’s condition (and the delivery of urgent treatment where indicated) increasingly difficult, thus creating an ongoing risk of future deaths.