“I heard evidence that there were significant staffing issues during the Ronald's period…”

The coroner’s concerns

– 1. I heard evidence that there were significant staffing issues during the Ronald's period of inpatient care that caused delays to his treatment. Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring. 2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies. 3. It is understood that the matter of staffing issues is not solely isolated to University Hospitals Birmingham NHS Foundation Trust, hence this report being sent to those organisations involved in its impact across the Health Board area. 4. The challenges are also national in nature. They are too big for a single doctor, nurse or paramedic to fix. They are too big for the hospital Trust to fix on its own, hence this report is also being sent to NHS England and the current Secretary of State for Health and Social Care in order for a cohesive and national approach to be co-ordinated and implemented. 5. I remain significantly concerned not only that delays are continuing and that deaths will continue to occur into the future, but also that there is inadequate cohesive forward thinking or planning either in relation short term pressures (eg. "winter pressures") or with a view to finding longer term solutions. 6. It is for you and your organisation(s) to take the action that is required to resolve the issues and to prevent future patients from dying avoidable deaths. It is not for me as Coroner to make recommendations on how you do that, therefore I leave matters in your hands.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0217

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0