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The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of adults with a diagnosed learning disability who attended/were admitted to hospital as an emergency between 1st July and 30th September 2024. Care was reviewed using 666 clinician questionnaires, 366 sets of case notes, 144 primary care questionnaires, 199 organisational questionnaires, 832 healthcare professional survey responses and 82 patient/carer surveys. Recommendations Accurately record a person’s identified learning disability in the electronic patient record/clinical notes and in learning disability registers/lists. This information should be accessible across healthcare settings to ensure prompt recognition and proactive care for patients with a learning disability on arrival at hospital. Assess and implement reasonable adjustments for patients with a learning disability. This should be undertaken: proactively if the reasonable adjustments have been flagged, and in place when the patient arrives in hospital; as soon as practicable after arrival/admission to hospital and be reassessed throughout the admission. Use decision support tools to aid healthcare professionals when assessing mental capacity in patients with a learning disability. Consistently and continuously involve people with a learning disability in their care during a hospital admission. This should be from the point of arrival through to discharge. Include:support from carers as appropriate; Reasonable adjustments at all stages, e.g., using communication tools to support conversations. Commission local learning disability support services to enable equitable access to care for patients with a learning disability who attend or who are admitted to hospital. Consider: using multidisciplinary community learning disability services to provide an in-reach service; upskilling all healthcare professionals to care for people with a learning disability; locally assessing how many patients are seen annually to determine the size of the service needed.

The estimated number of deaths linked to long waits in Emergency Departments across England has surged almost tenfold over the past decade.  That’s according to new analysis published in the Royal College of Emergency Medicine’s (RCEM) ‘State of Emergency Medicine in England’ report, which conservatively estimates that there were 15,860 excess deaths associated with long waiting times in English EDs in 2025.  That’s the lives of 305 people lost every week.  While the number of deaths is slightly lower than 2024 (16,644), further analysis reveals that the estimated mortality figure increased almost tenfold when compared to 2015 (1,657). RCEM’s report examines the scale of overcrowding in EDs and the impact this is having on patient safety and staff. Drawing on national data, research and frontline evidence from clinicians, it highlights how long waits, high bed occupancy and a lack of patient flow continue to lead to overcrowded emergency departments.  Long waits are closely linked to an increased chance of death within the following 30 days.   Further analysis for the previous year concerningly reveals nearly half a million people (489,138) waited 24 hours or more in EDs across England. This has increased by around 150,000 patients in just 3 years.  

NHS England is repeatedly addressing the wrong problem in emergency care. This HSJ article argues that national policy focuses on A&E “front door” measures (diversion, metrics, corridor care management) rather than the true cause of long waits: a shortage of inpatient beds and poor patient flow out of hospitals.

Corridor care has become one of the most significant patient safety challenges within the NHS, exposing individuals to avoidable harm and compromising their privacy, dignity, and overall clinical safety. This guide has been developed by NHS England to support clinical and operational leads by outlining the practical steps required to minimise and ultimately eliminate corridor care. Central to achieving this ambition is the adoption of GIRFT Clinical Operational Standards, which provide a consistent, trust-wide framework for timely clinical decision-making, improved patient flow across the urgent and emergency care pathway, and a reduced reliance on corridor care. It recognises the challenges trusts face in achieving this and acknowledge that elimination of corridor care is a longer-term ambition. Achieving sustainable reductions will require health and social care systems to work collaboratively to establish clear, accountable action plans. Responsibility for delivery should rest with the acute hospital Chief Executive and executive triumvirate (Chief Operating Officer, Chief Nursing Officer and Chief Medical Officer). Supporting resources: GIRFT Clinical Operational Standards Principles for providing patient care in corridors NHS England The Model ED NHS England The Model Acute Pathway NHS England » Extended emergency medicine ambulatory care (EEMAC) operating principles

A coronial investigation into the death of Roman Louie Barr, aged 22 who died on 14  December 2023, was opened on 20 June 2024 and concluded on 3 March 2026. The inquest was conducted without a jury. The conclusion reached was a short factual  narrative: “The deceased died as a result of an asthma attack. Information indicating the need for an  urgent ambulance response was not obtained, and because no ambulance was available for several hours, he was taken to hospital by his family. On the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death.”  On 14 December 2023, Roman Louie Barr suffered an asthma attack. His father collected him from work and took him home, where Roman used his nebuliser without improvement. Three calls were made to the ambulance service. During these calls, Roman was assessed as Category 2, and the family were twice advised that no ambulance would be available for several hours. They were asked whether they could transport him to hospital themselves and took the decision to do so. Evidence established that at the time of the first call, Roman was critically unwell, displaying symptoms including bluish lips, but this information was not elicited during triage. Roman was of mixed ethnicity and had a darker skin tone, as his father explained to the call handler. The NHS Pathways question requiring confirmation that the patient was “a deathly colour” was not understood by his father. Clearer prompts—such as asking whether the lips were blue or grey—were not asked. A recommendation made during the subsequent review to amend this NHS Pathways wording was not accepted by those responsible for the system’s content. Ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond. On the balance of probabilities, had clearer wording been used and the relevant information obtained, Roman would have been categorised as Category 1, for which an ambulance would be expected to arrive within approximately ten minutes even during surge conditions. While being driven to hospital, Roman suffered a cardiac arrest. His mother moved into the footwell of the passenger side and commenced CPR as they continued their journey. On arrival at the hospital, the family vehicle was involved in a collision, during which Roman’s mother sustained serious injuries. Roman could not be resuscitated and died shortly after arrival. I also heard evidence that Roman had been using his blue (salbutamol) inhaler more frequently than recommended, indicating poor asthma control, and that neither he nor his family were aware of the clinical significance of this increased use. Following his death, the GP practice conducted a review and introduced measures to better identify and monitor patients with high salbutamol use, including keeping a list of such patients, automatically booking reviews when further inhalers are requested, liaising with community pharmacists, and placing alerts on patient records to support timely assessment. Notwithstanding the Drug Safety Update issued on 25 April 2025 reminding clinicians of the risks associated with increased salbutamol use, the evidence in this case indicates that the importance of excessive reliever use may still not be fully recognised by patients or by primary care. Matters of concern Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress

ECRI's 2026 Top 10 reflects a shift toward broad, systemic threats that jeopardise safe, equitable and reliable care. This year’s list emphasises risks that span technology, infrastructure, staffing, culture, and public health—issues capable of affecting large numbers of patients and driving preventable harm. This year’s number one concern—navigating the AI diagnostic dilemma—underscores how unchecked dependence on AI tools can increase diagnostic errors, perpetuate bias and erode critical thinking skills. Although AI has immense potential to improve clinical workflows and expand access to expertise, the rapidly growing use of AI in healthcare raises serious safety and governance challenges. Several other topics highlight persistent obstacles—such as emergency department boarding and medication safety vulnerabilities in packaging and labelling design—that continue to strain the healthcare system. A few topics featured this year include: Reduced access to rural healthcare increases health risks and disparities. Increasing rates of preventable acute diseases. Effects of federal funding cuts on healthcare operations and patient safety. To effectively understand where vulnerabilities lie, leaders must examine all elements of their systems—people, organisations, tasks and processes, tools and technology and the physical environment. Each topic in this year’s Top 10 represents a failure in one or more of these interconnected areas.

This guidance sets out the core principles and components of high-performing emergency departments. It is accompanied by a detailed guide to the core operating principles for extended emergency medicine ambulatory care (EEMAC) activity. Together, they offer a structured, actionable approach to improving urgent and emergency care pathways and patient experience, as well as reducing waiting times. This guide is designed for providers, including: emergency department leaders (medical, nursing and operational leaders) considering implementing an EEMAC model hospital managers responsible for service implementation and resource allocation emergency department workforce (medical, nursing, allied health professions and administration) involved in patient triage, assessment and treatment. How to implement EEMAC successfully emergency department leadership team should establish the intended role and desired outcomes of EEMAC emergency department leadership team should ensure there is a well-understood model of emergency medicine, purpose and direction of travel Board-level medical, nursing and operational leadership should ensure multidisciplinary collaboration between local service teams emergency department clinical leaders and wider clinical teams should define clear patient pathways that align with the inclusion and exclusion criteria Estates teams and the ED team should together design the physical environment to optimise patient flow and comfort emergency department leadership team should establish a dedicated staffing model with appropriate clinical leadership Business intelligence and analytics teams should support the ED team to implement robust data recording practices for tracking and evaluating service performance. Core principles These principles apply to patients who attend the ED with an acute presentation. this EEMAC model applies to adult patients only the term EEMAC applies to patients expected to be discharged on the same day and whose care can be concluded by the ED team within 8 hours of transfer to the EEMAC unit. Patients requiring longer periods of observation will usually require admission to an inpatient area (for example, a CDU or short-stay ward) in common with other forms of SDEC, some EEMAC patients will require hospital admission – between 5% and 15% is expected patients suitable for existing medical, surgical, frailty or other SDEC pathways should be managed within those pathways as usual. Inclusion criteria patients who at initial assessment or via the rapid assessment and treatment (RAT) process are classified as acuity 3 or 4. Some acuity 2 patients, depending on individual patient needs and local departmental factors patients requiring advanced diagnostics, for example, CT or MRI or troponin result and senior clinical decision-making, but who have a high likelihood of being discharged within 8 hours patients whose investigation, management and treatment of their clinical condition is likely to take more than 4 hours, but who are likely to be suitable for discharge within 8 hours Exclusion criteria patients under the age of 16 patients suitable for existing medical, surgical, frailty or other SDEC pathways should follow those established routes low-risk primary care presentations should be directed to urgent treatment centres (UTCs). Acuity 5 patients are excluded patients requiring resuscitation facilities, those who are clinically unstable or those with presentations highly likely to result in admission should remain in the ED or be directed to appropriate alternative assessment and inpatient pathways patients with an acute mental health crisis who are at risk to themselves or the public or who are likely to require a medical or mental health admission patients who are acutely confused or intoxicated patients who are awaiting discharge or transfer; an EEMAC area is neither a discharge lounge nor an ‘overflow’ unit for other services patients awaiting admission to an inpatient bed patients who are being transferred from the ED without a valid clinical reason, where the only benefit from doing so would be to improve service time-based metrics – that is, the 4-hour standard patients requiring planned care (for example, follow-up or hot clinic activity). Location and environment EEMAC should ideally be co-located with ED but not within the ED footprint this estate should not be used for additional inpatient capacity or as an escalation space as part of a full capacity protocol the environment should be designed as an ambulatory clinic model, with chairs and minimal reliance on trolleys promoting efficient patient turnover. Comfortable waiting areas with access to refreshments should be available, and all other estate requirements should comply with the standards set out in the SDEC specification patients should have access to toilet facilities there should be no thoroughfare for staff or the public EEMAC facilities and estate should not compromise delivery of existing SDEC services or the ED. there should be provision for private discussions with patients, and the design of examination facilities should ensure patient comfort and support patient mobility (for example, access to recliner chairs and trolleys). Staffing and process the EEMAC area should have dedicated staffing, including a designated senior clinical decision-maker available during opening hours to ensure patient safety and maintain flow by ensuring rapid assessment and decision-making. There should be a separate, dedicated staff roster for EEMAC that includes, but is not limited to, senior decision-makers, medical and nursing staff, supported by administrative and operational support staff investigation and diagnostic turnaround times must be the same as for the ED all patients must have observations recorded at initial assessment to support assessment of acuity before transfer to the EEMAC area patients should be transferred to the EEMAC area as soon as possible after initial assessment patients who deteriorate while in EEMAC should be returned to the ED, following the hospital’s local standard process used in other specialty SDEC areas. Patients requiring admission should only remain in EEMAC while they wait for a bed and only if bed allocation is anticipated within the 8-hour time standard.

The task of managing mental health demand in A&E has attracted more attention in recent years, with the 10 Year Health Plan for England committed to investing up to £120 million to expand specialist mental health crisis centres, co-located with typical emergency departments, over the next decade. In this blog, Bea Taylor takes a closer look at the mental health care that’s currently provided in A&Es, and discusses the challenges that new specialist services will need to overcome.

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. The National Patient Safety Team identified a risk of harm from locked community public access defibrillator (CPAD) cabinets. CPADs are stored in numerous locations to allow members of the public to provide lifesaving defibrillation in the event of an out of hospital cardiac arrest. Most CPADs are kept in locked cabinets and require a 4-digit code to unlock the cabinet and release the CPAD. The code is usually provided by the ambulance service during a 999 telephone call. Several reports were reviewed where members of the public, who had been guided to a CPAD, could not get the unlock code or the incorrect code was held by the ambulance control centre. Working with NHS England cardiology colleagues, the National Patient Safety Team liaised with relevant stakeholders including the ambulance services in England, the Resuscitation Council (RCUK) and the British Heart Foundation (BHF), who maintain detailed mapping of CPADs and have researched their use. Discussions centred on the issues raised by our initial findings, such as why some cabinets are kept locked, how best to maintain data on CPAD access and use and how best to standardise an approach which would reduce delays in access. The outcome of these discussions highlighted the establishment of a National Defibrillator Network (The Circuit) and evidence from The Circuit showed that less than 1% of unlocked cabinets are vandalised, which is less than for locked cabinets. Whilst work on this issue is ongoing, a consensus statement has been issued by key stakeholders (NHS England, BHF, RCUK, St John Ambulance and the Association of Ambulance Chief Executives) which recommends “public access defibrillators should be placed in unlocked cabinets allowing immediate access in an emergency”.