It said not all cases needed to be transferred to specialist wards and some could be allowed home after treatment in the observation ward, once the necessary arrangements had been made with health and social services in the community.

BBC: 95-hour wait in casualty

"In relation to this particular inquest, we've already made changes to observation and escort policies on the ward and given nurses additional protected time to write up patient notes, " he added.

BBC: Bradgate Unit's 'failings' in Gagandip Singh Sandhu death