Recurring concern

Unreliable hospital destination selection for patient transfers

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First reported 22 Nov 2017•Latest report 7 Dec 2023

Definition

What this concern includes

Includes failures in selecting, confirming, communicating or routing patients to the appropriate hospital during ambulance transfers, hospital referrals or comparable patient-transfer arrangements, including disputes over the appropriate destination and incorrect or unclear receiving-hospital information.

Not included

Excludes delays, transport conditions or handover failures after the appropriate hospital destination has been reliably selected and communicated.
Excludes clinical decisions about treatment or transfer suitability where the hospital destination information itself is not deficient.
Excludes generic hospital-capacity, ambulance-response or referral-processing failures without a material destination-selection or receiving-hospital identification problem.
Excludes condition-specific referral pathways where destination selection is only incidental and the named condition or pathway provides the more specific supported concern.

Reports: 5
Individual concerns: 5
Date range: 2017–2023
Stated actions: 13

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Gloucestershire Hospitals NHS Foundation Trust1

Lancashire Teaching Hospitals NHS Foundation Trust1

Lewisham and Greenwich NHS Trust1

Liverpool Heart and Chest Hospital NHS Foundation Trust1

London Ambulance Service NHS Trust1

London Borough of Lewisham1

Manchester University NHS Foundation Trust1

South Western Ambulance Service NHS Foundation Trust1

Sydenham Green Group Practice1

University College London Hospitals NHS Foundation Trust1

University Hospitals Sussex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Dec2023
Inner North London
Concerns raised1
1. Delays and confusion in inter-hospital transfer coordination
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.
  Stated by University College London Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Sarah CHAPPELL · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays and confusion in inter-hospital transfer coordination
Wider context from the report
“1. There was a ten day delay in Ms Chappell’s transfer from the Princess Royal Hospital to UCLH. I was told that this might have been because of a lack of beds, but it might also have been because of confusion about which UCLH site was the accepting surgeon’s preferred destination, a confusion that was understood at the time by the Princess Royal to be a rejection of the transfer. ”
Source location
Sarah CHAPPELL · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.

Verbatim wording from the response
“Recognising that there was confusion between PRUH and UCLH relating to transfer we will develop a referral form for urology by May 2024 to improve documentation around the reason for transfer and agreed decisions to inform the plan of care. This will be led by the clinical lead for urology and will mirror some of our best practice referrals such as in the thoracic service.”

Source location
Response from University College London Hospitals
Page 3 · response
Published 19 December 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.

Verbatim wording from the response
“Ms Chappell was transferred to UCLH as an emergency referral from PRUH on 1st June 2023, as the team there believed she had suffered a perforation of her neobladder. She had been discussed by the PRUH team with a urology consultant on 22 May 2023 and accepted for transfer, however there were no available beds at the time at UCLH. PRUH appear to have organised Ms Chappell’s transfer to the UCLH Emergency Department without confirming with the Urology team at UCLH and Ms Chappell was subsequently admitted to a surgical ward (T14 north) when they had a bed available. Ms Chappell was then transferred to T14 Acute Surgical Unit on the evening of 1st June 2023.”

Source location
Response from University College London Hospitals
Page 3 · response
Published 19 December 2023
Open published response
29 May2020
Inner South London
Concerns raised1
1. Dispute over hospital destination during ambulance transfer
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Offer Coordinate My Care plans to patients with complex medical needs to share treatment information with other services.
  Stated by and the Sydenham Green Group PracticeStated completed
2. Action
  Update the policy governing conveyance of patients to appropriate hospital destinations by the end of October 2020.
  Stated by London Ambulance Service NHS TrustStated planned
3. Action
  Continue signposting and developing courses on communication issues, listening to parents, and patient-centred care for children with disability.
  Stated by Royal College of Paediatrics and Child HealthStated in progress
Respondent positions 1
1. Position
  Conveyance to the nearest emergency department was indicated, and the crew acted correctly under policy.
  Stated by London Ambulance Service NHS TrustDisputes the concern
AI-generated summary

Master Omarian Brooks · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Dispute over hospital destination during ambulance transfer
Wider context from the report
“2. There was also a distressing dispute between the ambulance crew and parents as to which hospital Omarian should be taken, in the event he was not taken to the nearest hospital at the insistence of his parents (although in this instance the delay was not found to have contributed to the death). ”
Source location
Master Omarian Brooks · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Offer Coordinate My Care plans to patients with complex medical needs to share treatment information with other services.

Verbatim wording from the response
“14. There were also lengthy discussions during the multi-agency meeting in respect of ‘Coordinate My Care’. This has been raised by other agencies as a way to have access to patient information from different agencies. The Practice has CMC embedded into their medical records system. The GPs have been using CMC regularly since its inception in 2015 for adult patients as a platform to share medical information with outside agencies such as London Ambulance Service, 111 and the local hospice. Unfortunately, the CMC was not available for children during the time of Omarian’s life. The GPs report that CMC is now available for children under the age of 18. The GPs have subsequently worked through CMC already with one family in the practice who have specific medical needs and will continue to offer it to all patients going forward.”

Source location
2020-0114-Response-from-Sydenham-Green-Group-Practice_Redacted-1.pdf
Page 3 · response
Published 10 June 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the policy governing conveyance of patients to appropriate hospital destinations by the end of October 2020.

Verbatim wording from the response
“The LAS’s position on conveying patients to the most appropriate destination is detailed in OP/014 Managing the Conveyance of Patients Policy and Procedure. During the inquest you were advised by Ms ████████, Sector Senior Clinical Lead, that this policy was due to be updated but due to the current pandemic it has not been possible for the LAS to carry out this update. The LAS endeavours to update this policy by the end of October 2020.”

Source location
2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 10 June 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue signposting and developing courses on communication issues, listening to parents, and patient-centred care for children with disability.

Verbatim wording from the response
“• Whilst we do not have all the details or specifics of the case, a breakdown in communication between the parents and health professionals involved in Omarian’s care may have occurred. The College will continue to signpost and develop courses that focus on ensuring awareness of communication issues in relation to children with disability, all of which emphasise the importance of listening to parents and of ensuring patient-centred care. We”

Source location
2020-0114-Response-from-the-Royal-College-of-Paediatrics-and-Child-Health_Redacted.pdf
Page 1 · response
Published 10 June 2020
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conveyance to the nearest emergency department was indicated, and the crew acted correctly under policy.

Verbatim wording from the response
“Given that this patient was presenting with a potentially critical illness, conveyance to the nearest emergency department was indicated. The acceptable exceptions to conveying the child to another hospital would not apply in an emergency situation for the nearest unit not being equipped to deal with a paediatric patient. This would not have been the case with Lewisham Hospital which has a paediatric emergency department.”

Source location
2020-0114-Response-from-London-Ambulance-Service_Redacted.pdf
Page 1 · response
Published 10 June 2020
Open published response
26 Sep2018
Manchester West
Concerns raised1
1. Failure to provide accurate referral destination information for aortic aneurysm treatment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Publish and distribute the Liverpool Acute Network for Thoracic Aortic Services pathway across the region and on the Trust website.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completed
2. Action
  Produce three regional referral pathways covering Cheshire and Merseyside, Wythenshawe and MRI, and Lancashire including Blackpool.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completed
3. Action
  Publish the Manchester and Lancashire referral pathway documents and distribute the pathways to emergency departments.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated planned
1. Action
  Finalise and obtain approval for the Lancashire and South Cumbria pathway for managing aortic aneurysms.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completed
2. Action
  Share the Lancashire and South Cumbria pathway and clinical algorithm with Medical Directors and Emergency Departments across the vascular network.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated planned
3. Action
  Confirm vascular clinicians’ awareness of the Lancashire and South Cumbria pathway and algorithm through clinical meetings and individual discussions.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated planned
4. Action
  Implement formally agreed written guidance for Greater Manchester acute aortic syndrome referrals and distribute it to covered hospitals and healthcare professionals.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completed
5. Action
  Continue consulting with Liverpool Heart and Chest Hospital and modifying Manchester’s referral guidance in line with wider cardiothoracic strategy and service specifications.
  Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated in progress
6. Action
  Develop a service specification for aortic aneurysm management, identifying specialist hospitals, team responsibilities, referral communication and clear pathways.
  Stated by Caroline Dinenage MPStated in progress
Respondent positions 1
1. Position
  NHS England and national cardiac and vascular clinical reference groups are responsible for developing the service specification and addressing aortic aneurysm pathways.
  Stated by Caroline Dinenage MPRedirects responsibility
AI-generated summary

Angela Mary Jackson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide accurate referral destination information for aortic aneurysm treatment
Wider context from the report
“i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons. The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital. ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital. iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence. iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams. v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment. ”
Source location
Angela Mary Jackson · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish and distribute the Liverpool Acute Network for Thoracic Aortic Services pathway across the region and on the Trust website.

Verbatim wording from the response
“A pathway was agreed between LiVES and LHCH and published known as Liverpool Acute Network for Thoracic Aortic Services (LANTAS), (Appendix 1). This was distributed around the region and placed on the LHCH Website.”

Source location
Angela-Jackson-Response-1
Page 2 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Produce three regional referral pathways covering Cheshire and Merseyside, Wythenshawe and MRI, and Lancashire including Blackpool.

Verbatim wording from the response
“Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.”

Source location
Angela-Jackson-Response-1
Page 3 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish the Manchester and Lancashire referral pathway documents and distribute the pathways to emergency departments.

Verbatim wording from the response
“Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.”

Source location
Angela-Jackson-Response-1
Page 3 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Finalise and obtain approval for the Lancashire and South Cumbria pathway for managing aortic aneurysms.

Verbatim wording from the response
“Prior to the inquest of Mrs Jackson, work had already begun within our organisation on producing a pathway for the Lancashire and South Cumbria Vascular Network. It is clear that this work needed to be extended to include the whole of the North West region incorporating all the specialist cardiothoracic centres and referring hospitals.”

Source location
Angela-Jackson-Response-1
Page 3 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the Lancashire and South Cumbria pathway and clinical algorithm with Medical Directors and Emergency Departments across the vascular network.

Verbatim wording from the response
“• Sharing both the pathway and clinical algorithm with all Medical Directors and Emergency Departments across the Lancashire and South Cumbria Vascular Network.”

Source location
Angela-Jackson-Response-1
Page 4 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Confirm vascular clinicians’ awareness of the Lancashire and South Cumbria pathway and algorithm through clinical meetings and individual discussions.

Verbatim wording from the response
“• Confirming awareness of the pathway and algorithm in doctors working within our vascular service at Lancashire Teaching Hospitals both through presentation at clinical meetings and individual discussions.”

Source location
Angela-Jackson-Response-1
Page 4 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement formally agreed written guidance for Greater Manchester acute aortic syndrome referrals and distribute it to covered hospitals and healthcare professionals.

Verbatim wording from the response
“The concerns are acknowledged in their entirety by Manchester University NHS Foundation Trust. Steps have been taken in order to create and work towards implementing formalised written guidance on the referral system to the Trust for treatment of patients with aortic aneurysms and other conditions. The pathway has now been formally agreed at the Trust”

Source location
Angela-Jackson-Response-1
Page 4 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue consulting with Liverpool Heart and Chest Hospital and modifying Manchester’s referral guidance in line with wider cardiothoracic strategy and service specifications.

Verbatim wording from the response
“Mr Bilal has consulted directly with colleagues at LHCH in respect of this written guidance; Mr Manoj Kuduvalli, Consultant Surgeon and Associate Medical Director for Surgery and Mr Mark Field, Aortic Lead, specifically considering alignment with the pathway provided by Mr Field on behalf of LHCH. Our Trust's guidance is agreed in principle by LHCH and is subject to ongoing consultation, discussions and modifications in line with wider cardiothoracic strategy and service specifications.”

Source location
Angela-Jackson-Response-1
Page 6 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a service specification for aortic aneurysm management, identifying specialist hospitals, team responsibilities, referral communication and clear pathways.

Verbatim wording from the response
“You will be interested to know that work has been commissioned for the national cardiac and vascular clinical reference groups to address the surgical management of aortic aneurysms (including descending thoracic aneurysms) and produce a service”

Source location
Angela-Jackson-Response2
Page 1 · response
Published 26 September 2018
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England and national cardiac and vascular clinical reference groups are responsible for developing the service specification and addressing aortic aneurysm pathways.

Verbatim wording from the response
“Your report raises concerns about the absence of documented pathways for the treatment of aortic aneurysms nationally. My officials have made enquiries with NHS England, as commissioner of specialised services, and I am able to offer the following information.”

Source location
Angela-Jackson-Response2
Page 1 · response
Published 26 September 2018
Open published response
11 Jul2018
Brighton and Hove
Concerns raised1
1. Failure to arrange early transfer to an appropriate specialist hospital
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Rita Elizabeth GILES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to arrange early transfer to an appropriate specialist hospital
Wider context from the report
“(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork. (2) The Trust’s own Transfer Policy not adhered too in any respect. (3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later. (4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement. There was a failure to appreciate that as she was already septic when she came in the matter was urgent. From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round. ”
Source location
Rita Elizabeth GILES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Nov2017
Gloucestershire
Concerns raised1
1. Lack of clarity about which hospital should treat the patient
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Susan Ann Smalley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Susan Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity about which hospital should treat the patient
Wider context from the report
“2. Whether clinicians, patients and paramedics are clear as to which hospital, either Gloucester Royal Hospital or Cheltenham General hospital, should be treating the patient. ”
Source location
Susan Ann Smalley · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays and confusion in inter-hospital transfer coordination

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Dispute over hospital destination during ambulance transfer

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide accurate referral destination information for aortic aneurysm treatment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to arrange early transfer to an appropriate specialist hospital

Concerns raised1

Lack of clarity about which hospital should treat the patient

Actions described in response 1

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 9

Respondent positions 1