A&E delays and excess deaths - is this the new normal?

The Royal College of Emergency Medicine recently estimated that the current logjam in A&E is leading to 300 to 500 deaths a week UK-wide which would otherwise have been avoided with timely care.

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The magnitude is open to debate, yes; but the fact that people are dying directly, and needlessly, as a result of A&E delays is not - even if our political leaders remain reluctant to admit it outright.

When pressed, Nicola Sturgeon conceded only that “delays in accessing healthcare have consequences and the consequences can involve harm for patients”.

There is growing alarm beyond the medical profession, however.

Professor Sir David Spiegelhalter, the UK's foremost statistician, said the country’s “continuing pattern of excess deaths deserves close scrutiny”.

After dipping in January and February, when Omicron-related restrictions remained in place, UK excess deaths during 2022 mostly remained higher than pre-pandemic averages (Image: Our World in Data)

With the exception of 2020 - the peak of the Covid pandemic - excess deaths in the UK in 2022 were among the highest in 50 years.

In Scotland, the number of people who died between mid-March and January 8th this year was 10 per cent higher than expected - an extra 4,785 deaths above the five-year average (2016-19 plus 2021).

Around one in three (35%) were Covid deaths, but the biggest increases were seen in "circulatory" deaths (strokes, heart attacks, brain haemorrhages etc - up 10%) and "other" deaths (anything except Covid, cancer, dementia, respiratory illnesses, or circulatory causes - up 21%).

It is no coincidence that this has happened at the same time as A&E has been unravelling, with record numbers spending over eight and 12 hours in emergency departments.

On some estimates, A&E gridlock may be the root cause for anything from around a quarter to more than half the excess deaths which are occurring.

A&E waiting times began to climb in summer 2021 and have been particularly high from March 2022 onwards (Image: PHS)

So how does it happen?

Wherever patients are in the UK, the same deadly chain is playing out. Social care shortages are leaving thousands of patients stuck in hospital for weeks longer than necessary (around one in eight beds in Scotland are being lost to patients whose discharge from hospital has been delayed).

Spikes in flu, Covid, and other respiratory infections during December wiped even more beds out of the system.

As a result, A&E departments are full - unable to find beds for the patients they need to admit, or space for new arrivals.

In some cases, critically ill patients who would normally be rushed straight to the resuscitation bay have been treated in corridors because resus is full.

Patients who would normally have been transferred into high-dependency units can spend days in A&E instead.

Meanwhile, ambulances stack outside - unable to offload patients (some of whom have deteriorated and died), and unable to respond to 999 calls.

In the final week of December, one in 10 patients arriving at Aberdeen Royal Infirmary by ambulance spent over five and a half hours waiting to be handed over.

Not all "A&E deaths" necessarily happen in A&E, however.

Research consistently shows that prolonged A&E stays for patients who require admission into a hospital bed are associated with an increased risk of death within 30 days.

New analysis this week by the Economist magazine - covering data up to July 2022 across 121 English NHS trusts - found a 10% increase in the proportion of A&E patients waiting between four and 12 hours for admission to a ward translated into an additional 1.2 deaths per 1,000 patients arriving at hospital.

READ MORE: Probe into ambulance deaths amid 'horrific' A&E handover delays

Meanwhile, Stuart McDonald, an actuary with LCP Health Analytics, said it was a “cautious assumption” that there is at least one avoidable death for every 72 patients who spend over 12 hours in emergency departments waiting for a hospital bed.

The estimate is based on a previous peer-reviewed study, published in the Journal of Emergency Medicine, which found one excess death within 30 days for every 82 patients who waited six to eight hours prior to admission between 2016 and 2018.

“It’s a cautious assumption because the research also showed that the longer the wait the more harm arising,” Mr McDonald told’s Radio Four’s ‘More or Less’ programme this week.

“They just didn’t have sufficient credible data during the period they studied to put a number on the additional harm that arises for 12 hours or more.”

Now, tragically, we have plenty of eight-hour, 12-hour - even 24-hour - waits, and longer.

These pernicious delays are where the bulk of the damage is done.

While headlines inevitably focus on the more explicit cause-and-effect examples of the current crisis - the ambulance taking hours to reach a heart attack patient who ultimately dies, the patient waiting in the back of an ambulance outside A&E who suffers a fatal cardiac arrest - these cases are still comparatively rare compared to the slow-burn, cumulative harm occurring as a result of A&E trolley waits.

READ MORE: NHS preparing for 'significant excess deaths' this winter 

There are a variety of reasons why these deaths occur: patients are more likely to pick up infections in overcrowded A&Es; exhausted staff juggling too many patients are more likely to make mistakes with medication or miss symptoms; elderly patients - especially those with dementia - are much more likely to deteriorate from prolonged exposure to noisy, over-lit environments, and the risk of delirium - and falls - increases.

Finally, these are patients who require specialist care on a specialist ward. The longer it takes to get them there, the more their chance of recovery diminishes.

These patients may not die in A&E - but they are ultimately dying because of it.

Much was made of a post-pandemic "new normal" - is this really it?