Table 7 Summary of key findings

• Many patients delayed seeking care for COVID and non-COVID causes.

• Delays in ambulance transport could be considerable and may have had an adverse effect.

• There were unforeseen consequences of the 111 service which resulted in delays.

• Patients with learning disabilities had the highest likelihood of higher avoidability scores.

• 1 in 3 deaths occurred in patients with dementia.

• Older patients in care homes had a low risk of avoidability.

• Older patients from their own home had a higher risk than younger patients.

• Below optimal care was the most common theme in cases most likely to be avoidable.

• There were often long delays in category 2 ambulance responses times early in the pandemic.

• Avoidability themes were noted in 49% of COVID deaths versus 23% of other deaths.