David Smart

REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Area Coroner, Joanne Andrews for the Coroner Area West Sussex, Brighton and Hove REPORT TO PREVENT FUTURE DEATH REGULATION 28 David John SMART, and an inquest that concluded on 19 May 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, University Hospitals Sussex NHS Foundation Trust provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 19 June 2026
3.

The MATTERS OF CONCERN were identified in the report are as follows: During the inquest I heard evidence that at the of Mr Smart's attendance to the Emergency Department of the Royal Sussex County Hospital, Brighton that there were around 20 patients in the corridor as the Department had reached capacity and there was no clinical area available to do so. I understand from previous inquests that the area is not designated as a clinical area.

I have heard in other inquests relating to deaths prior to June 2025 that is being taken by University Hospitals Sussex NHS Foundation Trust currently to (1) reduce the number of patients who present to the Emergency Department who could be seen by other services in the community and (2) to create an improved patient flow through the Royal Sussex County Hospital.

The evidence in this inquest was that, despite these actions, the corridor continues to be used when the Emergency Department reaches capacity.

I was also advised that the use of corridors to care for patients is not only an issue at the Royal Sussex County Hospital, Brighton but is used throughout the country.

Prevention of Future Death reports in relation to the use of the corridor for patient care was made during investigations into deaths which occurred in

December 2022 and February 2025 and the use of the corridor remains ongoing.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed.

The use of Emergency Department (ED) corridors to care for patients is a significant national problem. The Executive team is working closely with very senior members of the local ICB (Integrated Care Board), CQC (Care Quality Commission), local mental health Trust, and social care providers to tackle the problem. As a Trust we cannot solve the problem without all partner organisations working together. I am so sorry you have had the need to write to us again with your concerns and I too share these concerns.

The Medicine Divisional Leadership team, the Hospital Directors, and the Executive team are continuously working on several separate but linked workstreams aiming to eradicate the use of the ED corridor. This is vital for patient care to ensure that our patients are treated in the most appropriate clinical environment, with dignity, and without delays.

who are accepted for care directly by the relevant specialty on presentation to the ED. We are continually looking to expand the acceptance criteria to ensure that we are maximising this process. Additionally, we are directing inter-hospital referrals away from the ED and transferring patients directly to the in-patient bed base. We have strengthened our Same Day Emergency Care (SDEC) medical model from a 7 day a week service to a 24/7 unit where patients can be streamed away from the ED and seen and treated on the Acute Medical Unit (AMU). These workstreams have all been overseen through the ED Quality Oversight Group. The Trust is currently exploring working with a company (NEWTON) to increase the opportunity for decompressing the EDs, further strengthening the SDECs across the Trust, and improving flow once patients do not have a criteria to reside.

All specialties in-reach to the ED and we operate a 3/2/1 bleep system to week. These allow line-by-line reviews of every patient in the corridor to ensure all appropriate pathways are considered; this is known as check and challenge and provides live escalation.

The Hospital Alternative Oversight Programme (HALO) is embedded in daily practice and continues to be reviewed regularly to ensure all opportunities are maximised. This work is aimed at the avoidance of inappropriate hospital admissions, to optimise patient flow through the hospital, and smooth discharge pathways and processes. This includes:

Unscheduled care Navigation Hub Frailty Care Home Outreach & Red Bag Launch Frailty High Weald Lewes & Havens Outreach Integrated front door therapies team RSCH (Royal Sussex County Hospital) Virtual Health, both General Virtual Ward and Respiratory Home Monitoring Services Frailty and Respiratory SDEC (Same Day Emergency Care) Optimisation Interprofessional Standards UTC (Urgent Treatment Centre) Optimisation Early Discharge Planning Deconditioning Prevention Tiered Acuity Model

These initiatives are in collaboration with our colleagues from the ICB, Sussex Community NHS Foundation Trust (SCFT), South East Coast Ambulance Service (SECAmb), Sussex Partnership NHS Foundation Trust (SPFT), and Brighton & Hove City Council (BHCC).

There continues to be ongoing collaborative work with the local Mental Health Trust, SPFT to ensure that patients requiring mental health hospital admission are admitted to an appropriate mental health unit as quickly as possible or avoid ED attendance in the first place.

We continue to use ambulatory space as effectively as possible across the ED to maximise clinical space and reduce overcrowding.

The Continuous Flow Model is embedded within the Medicine Division and continues to ensure earlier movement of patients from the Acute Floor and reducing the time patients are waiting in the ED for admission to a ward. There are ongoing discussions with clinical Divisions outside the Medicine Division to implement a similar model.

We recognise that the contributory factors leading to corridor care are multi- faceted and complex. As these issues involve a multi-agency approach, working alongside our system partners, we acknowledge that eradicating care in non-clinical environments will take considerable time. Therefore, alongside these actions, the ED team is continuing to implement local measures to improve the quality and safety for patients receiving care in these areas. Examples of these are:

Digitisation, including electronic observations and prescribing Intentional Rounding Fundamental Standards of Care and Corridor standard work Weekly review of high risks Repurposing clinical space to facilitate dedicated space for monitoring patients who have been stepped down from the Resuscitation area of ED.

Our Acute Floor Reconfiguration, which is a £48 million capital improvement programme to improve patient and staff experience at the Royal Sussex County

Hospital, is well underway. The first phase has now been completed with the opening of the new Acute Medical Unit and 24/7 Medical SDEC (same day emergency care). Phase 2 is scheduled to commence in early 2027.
5. DETAILS OF FURTHER ACTION PROPOSED We all agree that corridor care must be stopped both locally and nationally. The Trust has made great progress with this and continues to work with the ICB and other organisations for their assistance to make sure flow in and out of ED is possible so when patients who do not require acute hospital care for a physical health condition, they are in appropriate mental health and social care environments outside of the acute Trust.
6. SIGNATURE Chief Executive University Hospitals Sussex NHS Foundation Trust

Dear Ms Andrews, Re: Regulation 28 Report to Prevent Future Deaths – David John Smart who died on 14th June 2025. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 22nd May 2026 concerning the death of David John Smart on 14th June 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Smart’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Smart’s care have been listened to and reflected upon.

Your Report raises concerns that corridors are being used to treat patients when hospitals have reached capacity across the country. You were concerned that corridor care was raised as a concern in two Prevention of Future Death Reports from December 2022 and February 2025 yet the issue continues to be a concern. NHS England is clear that corridors are not designated clinical areas and their use for patient care is a symptom of significant system pressure rather than planned practice. Since your previous Reports to us, the NHS England Urgent and Emergency Care Plan for 2025/26 has been published (in June 2025) and supported by the Medium- Term Planning Framework, which sets out a national expectation that systems take coordinated action to eliminate corridor care by improving end-to-end patient flow, reducing avoidable hospital congestion and improving timely discharge from hospital. Alongside this, NHS England has been and continues to support providers and Integrated Care Boards (ICBs) to improve internal hospital flow through faster senior clinical decision-making, increased use of same day emergency care and virtual wards, and more effective management of patient pathways. The plan also aims to reduce demand on emergency departments through improved access to community and primary care alternatives and strengthened admission avoidance pathways, so that patients can be assessed and treated in the most appropriate setting. A key element of improving patient flow is reducing delays in discharging patients who no longer require acute hospital treatment. Delayed discharges contribute to high bed occupancy, reducing capacity for emergency admissions and increasing pressure on emergency departments. NHS England is supporting providers and ICBs to strengthen National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

7 July 2026

discharge processes, including through the consistent use of criteria-led discharge and discharge to assess models. NHS England is also developing “Model Discharge” guidance to support trusts in reducing delays and improving patient flow. NHS England recognises that, despite these actions, corridor care is still used in exceptional circumstances in some providers when emergency departments are under sustained capacity pressure. This is primarily to enable ambulances to be released rapidly from hospitals, to address increased risk in the community. This reflects wider system flow challenges, including constrained bed capacity, delayed discharges and limited community care availability. To strengthen oversight and drive improvement, NHS England is working through regional teams to provide targeted support to systems experiencing the highest levels of flow pressure. From May 2026, the routine publication of corridor care data has begun, increasing transparency and enabling more focused intervention where risks to patient safety are greatest.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mr Smart, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.