Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
What is not included
Ordinary shift handover with no transfer of the patient or care responsibility
Clinical treatment failures after a safe and complete transfer
Discharge to the community where no healthcare transfer process is involved
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England14
Department of Health and Social Care10
University Hospitals Sussex NHS Foundation Trust5
Betsi Cadwaladr University LHB4
HM Prison and Probation Service4
Manchester University NHS Foundation Trust4
Swansea Bay University Local Health Board4
University Hospitals of Derby and Burton NHS Foundation Trust4
Welsh Government4
Greater Manchester Mental Health NHS Foundation Trust3
Healthcare Inspectorate Wales3
Stockport NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust2
Bedfordshire Hospitals NHS Foundation Trust2
NHS trust66
Executive non-departmental public body15
Healthcare site13
Ministerial department11
Local health board10
Type not available7
Residential care home5
Devolved government4
Executive agency4
Health and care inspectorate3
Independent healthcare provider3
Prison or young offender institution3
Private limited company3
Company limited by guarantee2
Health and social care service regulator2
Reports and published responses 103 reports
See individual reports that have raised this concern, and the actions taken in response
Nottinghamshire
Concerns raised1
Lack of a system for prioritisation of urgent surgical patients awaiting transfer
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Develop and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Tailor the tracking system to orthopaedic standards and complete its implementation.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Discuss implementation of the tracking system with wider specialties for surgical patients.
Worcestershire
Concerns raised1
Absence of a formal, documented handover system between hospital and Neighbourhood Team
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Herefordshire and Worcestershire Health and Care NHS Trust
Worcestershire Acute Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS Trust
Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.
Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS Trust
Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.
Essex
Concerns raised1
Failures to organise and coordinate inter-hospital transport
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Mid and South Essex NHS Foundation Trust
The transfer delay did not affect the clinical outcome because appropriate care was provided at Basildon Hospital.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Mid and South Essex NHS Foundation Trust
Urgent transfers are prioritised by the Trust and East of England ambulance service.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Failure to give sufficient weight to continuity of clinical care in transfer decisions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cornwall Partnership NHS Foundation Trust
Royal Cornwall Hospitals NHS Trust
University Hospitals Plymouth NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Transfer to Derriford Hospital was correct because urgent assessment was required and it provided the closest prompt access to acute care.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
The assessing ambulance crew has paramount responsibility for the clinical decision about a patient's conveyance destination.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Community-based care and transfer to Liskeard were appropriate because there was no urgent need for orthopaedic revision surgery.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Transfers between Liskeard Community Hospital and Derriford Hospital were appropriate and reasonable based on the patient's clinical presentation.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Coventry and Warwickshire
Concerns raised1
Lack of consistent understanding of responsibility for initiating patient transfers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
George Eliot Hospital NHS Trust
NHS England
The British Transplantation Society
UK Kidney Association (UKKA; formerly the Renal Association
University Hospitals Coventry and Warwickshire NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
The British Transplantation Society and UK Kidney Association (UKKA; formerly the Renal Association
Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
University Hospitals Coventry and Warwickshire NHS Trust
Make UHCW the primary specialist transfer centre and accept all renal patients admitted to GEH, regardless of their parent hospital.
University Hospitals Coventry and Warwickshire NHS Trust
Operate a daily 11:30am huddle with the Medicine Operational team, including a renal doctor, to identify and prioritise interhospital transfers.
University Hospitals Coventry and Warwickshire NHS Trust
Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
University Hospitals Coventry and Warwickshire NHS Trust
Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
University Hospitals Coventry and Warwickshire NHS Trust
Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
University Hospitals Coventry and Warwickshire NHS Trust
Accept responsibility for recommending the best care location for patients referred to Renal Services.
George Eliot Hospital NHS Trust
Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
NHS England
Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
University Hospitals Coventry and Warwickshire NHS Trust
The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
George Eliot Hospital NHS Trust
Existing consultant-to-consultant transfer arrangements and the renal specialist service-level agreement are considered sufficient for transferring patients when required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Lack of shared understanding and expectations between medical teams about how Patient Pass operates
Linked response
Northern Care Alliance NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Northern Care Alliance NHS Foundation Trust
Convene a cross-Trust working group, review the incident, and agree actions to improve understanding and operation of Patient Pass.
Northern Care Alliance NHS Foundation Trust
Finalise and circulate a communications guide clarifying Patient Pass purposes and referrer and receiver responsibilities across Greater Manchester hospitals.
Northern Care Alliance NHS Foundation Trust
Add a new-user Patient Pass screen explaining user responsibilities and requiring acceptance before system access.
Northern Care Alliance NHS Foundation Trust
Create, consult on, and circulate a seven-minute Greater Manchester briefing sharing learning on applying transfer policies and using Patient Pass.
Dorset
Concerns raised1
Lack of national guidance for healthcare handover to receiving prisons
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Lack of a transfer protocol or pathway for transition from childhood to adulthood
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Sheffield Children'S NHS Foundation Trust
Sheffield Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Operate an agreed cross-trust transition pathway covering records, individual plans, transfer information and attendance at the first adult appointment.
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Provide specialist transition-team support, including multidisciplinary discussions and assistance with initial adult appointments or inpatient ward visits for young people with complex needs.
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Run a monthly transition clinic for hydrocephalus patients aged 14 and over, with extended appointments covering clinical review and transition preparation.
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Formalise the transition process in a written pathway clarifying how young people with shunts move from children’s to adult services.
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Participate in the regional innovator project to standardise developmentally appropriate transition care, including defined roles, staff training, personalised plans and patient tracking.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation Trust
Routine shunt reviews are not clinically required after transition; patients remain able to seek advice about symptoms or concerns.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised1
Failure to communicate relevant clinical information before transfer
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cardiff & Vale University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Cardiff & Vale University LHB
Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Suffolk
Concerns raised1
Lack of clarity in the categorisation process for urgent inter-hospital transfers
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
NHS England
Maintain and update the national framework for inter-facility ambulance transfers.
The Trust
Review the National Framework for Inter-Facility Transfers with NHS England in light of the death.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.