Recurring concern

Unreliable healthcare patient transfer processes

Get email alerts

Request correction

First reported 17 Sep 2013•Latest report 24 Jun 2026

Definition

What this concern includes

Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.

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

Reports: 103
Individual concerns: 131
Date range: 2013–2026
Stated actions: 151

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.

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

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.

10 May2021
Brighton and Hove
Concerns raised1
1. Failure to transfer patients requiring higher-level care to appropriate critical care facilities
This report raised 3 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

Mr. John Charles LOTT · 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

John Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.

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 transfer patients requiring higher-level care to appropriate critical care facilities
Wider context from the report
“(1) On 27ᵗʰ October 2020, Mr. Lott’s NEWS 2 scores were so high as to require transfer to a hospital with appropriate critical care facilities not available at the Brighton Nuffield. (2) On the 29ᵗʰ October Mr. Lott’s hypoglycaemia was not being managed. He should have been transferred. ”
Source location
Mr. John Charles LOTT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Apr2021
East London
Concerns raised1
1. Failures in transfer of patients with suspected aortic dissection to specialist centres
This report raised 7 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

Mr Paul Sartori · 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

Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.

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
Failures in transfer of patients with suspected aortic dissection to specialist centres
Wider context from the report
“Evidence was heard at the Inquest from an independent cardio thoracic surgeon. During the course of his evidence he stated that in his professional experience, far too many doctors are missing the diagnosis of thoracic aortic dissection. The expert confirmed that the tools to make the diagnosis are readily available in A & E departments. He considered that what is required is a full history and clinical assessment, to include bilateral radial pulses and bilateral blood pressures. If there is a differential between the bilateral pulses and bilateral blood pressures, then a CT scan should be carried out to rule out an aortic dissection. The expert confirmed that misdiagnosis of aortic dissection is a very common problem. During the course of the Inquest, information was also provided by the organisation “THINK AORTA”. They stated that: Our experience is that misdiagnosis of acute aortic dissection is a systemic issue in the NHS which currently leads to many unnecessary deaths. Three main factors underpin the problem of misdiagnosis: i. Lack of awareness and education ii. Access to CT scanning iii. Transfers to specialist centres The THINK AORTA campaign confirmed that those units that have successfully implemented THINK AORTA to prevent misdiagnosis typically do more than just display the THINK AORTA posters. They embed THINK AORTA in their education and practice by running education sessions two or three times a year and actively questioning patients with chest pain. Correspondence was also presented at the Inquest from the Aortic Dissection Charitable Trust. They also highlighted that in half of patients presenting with Acute aortic dissection, the diagnosis is not considered and about a third of patients are actively treated for the wrong diagnosis. They estimated that in the UK around 500 patients each year die from acute type A aortic dissection, due to a delayed diagnosis or failure to make the diagnosis. They have questioned whether current decision making tools and risk scoring tools are sensitive enough to: i. Reliably diagnose or exclude aortic dissection ii. They confirm their view that education about acute aortic dissection should include all clinicians in the patients’ pathway from first responders to radiologists and they highlight areas that education should focus upon. The above evidence raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection. ”
Source location
Mr Paul Sartori · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. Failure to formalise urgent ophthalmic patient transfer arrangements
This report raised 7 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 implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  A formal urgent-transfer agreement may not prevent similar incidents, so the concern is addressed through responsive protocols within existing services.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Douglas OWENS · 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

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 formalise urgent ophthalmic patient transfer arrangements
Wider context from the report
“(1) That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital when appropriate. Unless arrangements are formalised, the lives of patients may be put at risk. ”
Source location
Douglas OWENS · Prevention of Future Deaths report
Page 1 · 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 implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.

Verbatim wording from the response
“The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 1 · response
Published 3 December 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
A formal urgent-transfer agreement may not prevent similar incidents, so the concern is addressed through responsive protocols within existing services.

Verbatim wording from the response
“The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 1 · response
Published 3 December 2020
Open published response
14 Oct2020
Derby and Derbyshire
Concerns raised1
1. Failure to keep patient transfer information on one database
This report raised 4 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

Mr Edward Cowey · 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

Mr Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.

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 keep patient transfer information on one database
Wider context from the report
“1. That patient electronic and paper based transfer information is not kept on one database. Mr Coweys’ handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes; ”
Source location
Mr Edward Cowey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Nov2019
Manchester City
Concerns raised1
1. Unavailability of completed guidance and protocol for transfers from Manchester Royal Infirmary to Park House
This report raised 4 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

Charlotte Elizabeth Jacobs · 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

Charlotte Jacobs suffered an accidental fall at home on 11 October 2016, developed a deep tissue injury and sacral ulcer, later suffered a stroke, and died from heart failure and related disease on 31 October 2016. Concerns included the failure to assess her capacity to refuse treatment, fluids and nutrition, an inappropriate transfer to a psychiatric ward while she was physically unwell, continuing uncertainty about the appropriateness of such transfers, and incomplete transfer guidance.

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
Unavailability of completed guidance and protocol for transfers from Manchester Royal Infirmary to Park House
Wider context from the report
“1. The Consultant in charge of Ms Jacobs’ care (who authorised Ms Jacobs’ discharge on the 28th October 2016 to Maple Ward) indicated that – if similar circumstances arose again – he would make the same decision to transfer a patient to the Psychiatric Unit, despite the findings of the internal trust investigation that the discharge/transfer to Maple Ward should not have taken place. 2. The Consultant in charge of Ms Jacobs’ care still did not appear to understand that it was his role (and the role of those involved in treatment of Ms Jacobs’ physical illness) to consider whether a capacity assessment was required and to carry that out. This was not the role of the Psychiatric team. 3. The Consultant in charge of Ms Jacobs’ care and the Ward Manager for Ward 46 (at the time in 2016) did not appear to be aware of the findings of the Trust’s internal investigation. 4. Whilst I was informed that steps were being taken to put together guidance and a protocol for transfers of patients from Manchester Royal Infirmary to Park House, this had not been completed (despite Ms Jacobs’ death occurring some time ago in 2016). In light of this evidence, I am concerned that there could be further inappropriate discharges/transfers from Ward 46 and/or from Manchester Royal Infirmary generally, leading to a risk of future deaths. ”
Source location
Charlotte Elizabeth Jacobs · Prevention of Future Deaths report
Page 3 · concerns
Open source report
30 Sep2019
Manchester South
Concerns raised1
1. Limited availability and low prioritisation of transport for frail elderly patient transfers
This report raised 7 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

Mary Jones · 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

Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

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
Limited availability and low prioritisation of transport for frail elderly patient transfers
Wider context from the report
“1. Mary Jones was a frail elderly lady who was moved from the MRI to Trafford General post-operatively for rehabilitation under the Trust structure. It was a planned transfer. However due to limited transport availability she arrived at Trafford General out of hours after waiting for transfer. As a result she was clerked in and risk assessed out of hours despite the recognised risks of moving frail elderly patients out of hours. The inquest was told that this is not uncommon as transfers such as these are made via ambulance and are a low priority and moved where needed; ”
Source location
Mary Jones · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Sep2019
London Inner (North)
Concerns raised1
1. Lack of sharing of critical patient information between departments before transfer to PICU
This report raised 5 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 8
1. Action
  Mandate attendance, cover, documentation and case-discussion requirements for the spinal MDT and other required specialties.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completed
2. Action
  Use Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completed
3. Action
  Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completed
1. Action
  Expand Anaesthetic Pre-Operative Assessment triage to elective general-anaesthetic patients and identify high-risk patients for Complex Patient MDT planning.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated planned
2. Action
  Develop Trust-wide best-practice guidance for MDT attendance, documentation, information dissemination and completion of resulting actions.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated in progress
3. Action
  Disseminate agreed Trust-wide MDT attendance and documentation requirements to operational clinical teams.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated planned
4. Action
  Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated completed
5. Action
  Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
  Stated by Great Ormond Street Hospital for Children NHS Foundation TrustStated in progress
AI-generated summary

Amy Allan · 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

Amy Allan underwent elective corrective spinal surgery on 4 September 2018 and subsequently suffered severe deterioration, requiring ECMO support before dying on 28 September 2018. Concerns included inadequate pre-operative planning for ECMO, poor communication and handover between departments, extubation while her condition was deteriorating, delayed ECMO support, and a lack of clear co-ordination of her post-operative care.

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 sharing of critical patient information between departments before transfer to PICU
Wider context from the report
“I am concerned that: (a) It appears there was a lack of awareness and sharing of information between departments at Great Ormond Street Hospital. In particular, the PICU had not been given any advance warning of Amy’s complex medical background and needs before she was admitted there post operation. As PICU staff were not invited to the Multi-Disciplinary Team meetings prior to the operation, they were not aware of the “critical time” which lay ahead for her; (b) There was no clear plan or instruction for the management of Amy post operation in relation to extubation and ECMO support on the PICU; (c) The handover between clinicians involved in Amy’s operation and those taking over her care in the PICU, was poorly executed with vital information either not properly conveyed or recorded or simply missed; (d) There was a delay in commencing ECMO support, and (e) No single properly informed clinician appeared to be co-ordinating Amy’s post-operative care in such a complex and high risk case. ”
Source location
Amy Allan · 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
Mandate attendance, cover, documentation and case-discussion requirements for the spinal MDT and other required specialties.

Verbatim wording from the response
“The PICU Consultant is an important member of the spinal MDT meeting as many of the spinal patients are initially cared for in PICU post operatively. When Amy’s case was discussed at the spinal MDT meetings, the PICU consultant was not present. Although routinely invited to the monthly spinal MDT meeting, and were specifically invited to both of the spinal MDTs at which Amy was discussed, the PICU consultant was unable to attend. The Terms of Reference (TOR) for the MDT have now been amended to mandate the need for the attendance of the identified PICU consultant who acts as liaison with the Spinal Team. The TOR also now reflects the responsibility of the PICU consultant to arrange appropriate PICU consultant level cover for the spinal MDT meeting in the event that they are unable to attend.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 2 · response
Published 13 November 2019
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
Use Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.

Verbatim wording from the response
“In April 2019 the Trust launched a new electronic patient record system (Epic) that replaces the previous paper records and combines numerous existing electronic systems. Epic now enables the notes of MDT meetings to be recorded directly within the individual patient’s records. It is therefore much easier for all teams involved in caring for a patient to access the outcome of the MDT discussions. Epic also includes a messaging system (similar to email) within the patient’s records to support clinicians discussing the patient’s care and to ensure that those messages are directly linked to the patient’s records. This provides a much better awareness and sharing of information between departments.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 2 · response
Published 13 November 2019
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
Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.

Verbatim wording from the response
“In addition to the safety improvements which Epic brings, the Trust has made a number of changes to ensure that the outcome of the spinal MDT meeting are effectively communicated. This includes:”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 2 · response
Published 13 November 2019
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
Expand Anaesthetic Pre-Operative Assessment triage to elective general-anaesthetic patients and identify high-risk patients for Complex Patient MDT planning.

Verbatim wording from the response
“In addition to strengthening the pathways for spinal patients with complex co-morbidities, the Trust has also reviewed how it can apply the learning from Amy’s case to other surgical pathways. As a result two significant projects are now underway:”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 3 · response
Published 13 November 2019
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 Trust-wide best-practice guidance for MDT attendance, documentation, information dissemination and completion of resulting actions.

Verbatim wording from the response
“• Improving the governance of MDT meetings ○ Amy’s journey demonstrated how important it is that the Trust has good governance arrangements in place for all MDT meetings to ensure that all relevant clinicians are in attendance; that meetings are appropriately documented and the information disseminated effectively to the right staff; and that all actions arising from MDTs are completed; ○ A consultant surgeon has been identified by the Medical Director to lead a project to guide best practice in conducting MDTs across the Trust. This began in October 2019; ○ Trust wide requirements for MDT attendance and documentation have now been agreed. The requirements will be shared with the Operational Board on the 11th December 2019 for dissemination to operational clinical teams to action.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 3 · response
Published 13 November 2019
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
Disseminate agreed Trust-wide MDT attendance and documentation requirements to operational clinical teams.

Verbatim wording from the response
“• Improving the governance of MDT meetings ○ Amy’s journey demonstrated how important it is that the Trust has good governance arrangements in place for all MDT meetings to ensure that all relevant clinicians are in attendance; that meetings are appropriately documented and the information disseminated effectively to the right staff; and that all actions arising from MDTs are completed; ○ A consultant surgeon has been identified by the Medical Director to lead a project to guide best practice in conducting MDTs across the Trust. This began in October 2019; ○ Trust wide requirements for MDT attendance and documentation have now been agreed. The requirements will be shared with the Operational Board on the 11th December 2019 for dissemination to operational clinical teams to action.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 3 · response
Published 13 November 2019
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 the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.

Verbatim wording from the response
“The Spinal MDT TOR have been amended to include the specific responsibilities for clinicians attending the meeting in regards to ECMO. This is reiterated in the PICU guidance for managing spinal patients. A copy of this guidance is enclosed [Spinal Surgery Pathway PICU FINAL].”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 4 · response
Published 13 November 2019
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, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.

Verbatim wording from the response
“The Electronic Patient Record department is currently supporting the Anaesthetic and ICU teams to develop a standardised electronic handover document which mirrors the paper form which has been developed for this purpose. The electronic handover document will ensure that all the relevant fields are together in one section so that they can be clearly and easily discussed as part of a structured verbal handover, and act as an ongoing plan to support the ICU team.”

Source location
2019-0343-Response-by-Great-Ormond-Street-Hospital-for-Children
Page 5 · response
Published 13 November 2019
Open published response
18 Apr2019
Gloucestershire
Concerns raised1
1. Insufficient handover of patient safety information during transfers between wards
This report raised 3 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 2
1. Action
  Undertake the Silver quality-improvement project to improve identification of individual falls risks and consistent use of preventative measures through the Safety Hour Checklist.
  Stated by Gloucestershire Hospitals NHS Foundation TrustStated in progress
2. Action
  Trial modified nurse handover documentation that consolidates safety information and previous handovers across clinical areas on one form.
  Stated by Gloucestershire Hospitals NHS Foundation TrustStated in progress
AI-generated summary

Graham Philip Jones · 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

Graham Philip Jones, a 63-year-old man with significant medical conditions, was admitted to hospital with vomiting and abdominal pain and underwent repair of a perforated duodenal ulcer. He suffered several falls in hospital, including a fall that caused a significant head injury; the injury was diagnosed after a delay, and he died on 13 April 2018. The principal concerns related to falls prevention, adherence to the post-falls protocol, review of medication after a fall, and the handover of safety information between wards.

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
Insufficient handover of patient safety information during transfers between wards
Wider context from the report
“1. Whether sufficient consideration is given to falls prevention measures on the surgical ward, 2. Whether there is sufficient understanding of the post falls protocol that must be followed on the surgical ward, 3. Whether there is sufficient understanding that a medical review of a patient post fall must include review of their current medications, 4. When a patient is transferred between wards, whether there is sufficient handover of safety information pertaining to a patient. ”
Source location
Graham Philip Jones · 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
Undertake the Silver quality-improvement project to improve identification of individual falls risks and consistent use of preventative measures through the Safety Hour Checklist.

Verbatim wording from the response
“Evidence was heard from ████████ at the inquest about specific measures being taken to improve staff awareness and appreciation of falls prevention and management on Ward 5b. One main measure is the Silver QI project being undertaken by ████████, part of which is directed at reducing the risk of falls by more reliably acquiring knowledge of individual patient risks, and also ensuring more consistent use of preventative measures eg magnet signage above patients beds (see attached Driver diagram and GSAIA Quality Improvement summary which details the issues to be addressed). The aim of the project is to increase completion of the First Hour Priority Form (renamed Safety Hour Checklist) by 70% by May 2019. This form will record (amongst other factors) the handover of any falls risks for the patient being transferred.”

Source location
2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Trial modified nurse handover documentation that consolidates safety information and previous handovers across clinical areas on one form.

Verbatim wording from the response
“• The Trust nurse handover documentation is currently subject to a Quality Academy Silver project to be presented in June ████████ (Ward 5a) and ████████ (Ward 5b) have trialled a modification to the usual handover process. The modification now enables all previous handovers information from all clinical areas where the patient has been placed to be contained on one form, rather than on several forms from each of the previous clinical settings - the intention is that this will ensure that receiving ward can see a complete history of concerns during that admission of concerns from all the previous clinical settings from which the patient has been transferred, thus giving a more complete picture. This was not available for Mr Jones.”

Source location
2019-0131-Response-by-Gloucestershire-Hospitals-NHS-Trust
Page 2 · response
Published 14 June 2019
Open published response
5 Apr2019
Surrey
Concerns raised1
1. Failure to provide medical professional accompaniment or escort to the radiography suite
This report raised 10 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

Mrs Alice Doris Dixon · 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

Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

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 medical professional accompaniment or escort to the radiography suite
Wider context from the report
“1. The evidence before the court suggested that Mrs Dixon was not accompanied or escorted by a medical professional to the radiography suite. ”
Source location
Mrs Alice Doris Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Apr2019
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to transfer complete discharge documentation to the community hospital
This report raised 3 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

Terence Douglas Thornton · 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

Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

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 transfer complete discharge documentation to the community hospital
Wider context from the report
“BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”
Source location
Terence Douglas Thornton · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to transfer patients requiring higher-level care to appropriate critical care facilities

Concerns raised1

Failures in transfer of patients with suspected aortic dissection to specialist centres

Concerns raised1

Failure to formalise urgent ophthalmic patient transfer arrangements

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

Failure to keep patient transfer information on one database

Concerns raised1

Unavailability of completed guidance and protocol for transfers from Manchester Royal Infirmary to Park House

Concerns raised1

Limited availability and low prioritisation of transport for frail elderly patient transfers

Concerns raised1

Lack of sharing of critical patient information between departments before transfer to PICU

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.8

Concerns raised1

Insufficient handover of patient safety information during transfers between wards

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.2

Concerns raised1

Failure to provide medical professional accompaniment or escort to the radiography suite

Concerns raised1

Failure to transfer complete discharge documentation to the community hospital

Actions described in response 1

Respondent positions 1

Actions described in response 8

Actions described in response 2