Recurring concern

Unreliable healthcare patient transfer processes

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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.

16 Apr2015
West Yorkshire (West)
Concerns raised1
1. Failure to maintain safe systems of transfer while patients are being transferred
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.

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

Jeanne Elsie Summers · 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

Jeanne Elsie Summers was admitted to hospital with an exacerbation of chronic obstructive pulmonary disease and infection, and later suffered an unwitnessed fall while mobilising to the toilet, resulting in an open right ankle fracture. She subsequently developed pneumonia and died on 24 July 2013. Concerns included the absence of a clear mobility assessment before discharge, incomplete physiotherapy records, unsuitable footwear and unsafe transfer practices, and inadequate investigation of the fall.

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 maintain safe systems of transfer while patients are being transferred
Wider context from the report
“(3) From the evidence presented at the inquest it appears that at the time when Mrs. Summers was mobilising in the early hours of the 14th July 2013 she was wearing her own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers at the time. In addition the health care assistant who was supervising Mrs Summers did not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he left her. I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer. ”
Source location
Jeanne Elsie Summers · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to complete transfer documentation between wards
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

Robert Henry Payne · 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

Robert Henry Payne was admitted to hospital after falling at home and fracturing his left neck of femur. While in hospital, he experienced repeated falls, including one that dislocated the repaired hip and necessitated further surgery; the reported concerns included falls despite high-risk assessments and a ward transfer without an apparent transfer document, followed by a fall that was not witnessed. He later developed an infected surgical wound and died on 13 July 2014.

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 complete transfer documentation between wards
Wider context from the report
“(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014. (2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed. ”
Source location
Robert Henry Payne · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Dec2014
Nottinghamshire
Concerns raised1
1. Failure to ensure that immediate transfers at age 18 are in the person's best interests
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.
Respondent positions 3
1. Position
  The cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.
  Stated by Department of Health and Social CareUnable to act
1. Position
  The transfer was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.
  Stated by Department of Health and Social CareDisputes the concern
2. Position
  Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Rebecca Louise Overy · 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

Rebecca Louise Overy died from hypoxic brain injury caused by asphyxia while in adult secure mental health detention. Her fatal injury was self-inflicted after she was transferred from child and adolescent secure mental health detention to an adult admission ward the day after her 18th birthday, without a gradual transition plan; concerns included the immediate transfer and the lack of secure mental health care for young adults aged 18–24 with a similar clinical picture.

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 ensure that immediate transfers at age 18 are in the person's best interests
Wider context from the report
“1. That the immediate transfer of Miss Overy the day after her 18th birthday was not in her best interests, was detrimental to her mental health and occurred purely due to the operation of s 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer, and the clinicians to concur with it, lest they be in breach of the act. ”
Source location
Rebecca Louise Overy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
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 cited legislation is not known to require immediate transfer, preventing comment on that specific issue pending clarification.

Verbatim wording from the response
“You refer to the “operation of a section 30 of the Health and Social Care Act, whereby the commissioners were obliged to arrange an immediate transfer”. I am not aware of a provision from either the Health and Social Care Act or the Mental Health Act which stipulates this, so am unable to comment on this specific matter. However, if you are able to provide clarification for this reference I am happy to respond further on this point.”

Source location
2014-0535R
Page 3 · response
Published 17 December 2014
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 was planned for months, clinically assessed as appropriate, and could not safely be delayed or replaced by community discharge.

Verbatim wording from the response
“NHS England have assured me that Miss Overy’s future care had been considered for many months prior to her transfer including the appropriate type of environment and level of security required. They have confirmed that an independent clinical access assessment had been undertaken that identified that Miss Overy should be in an adult low secure placement when she turned 18. The CAMHS placement where she was, was not of a low secure environmental or therapeutic standard that would meet her identified needs. In addition, Miss Overy’s significant levels of risk and patterns of behaviour meant that she would not have been able either to remain within a CAMHS or be discharged to the community when she became an adult.”

Source location
2014-0535R
Page 3 · response
Published 17 December 2014
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
Existing adult wards and transition guidance are considered capable of meeting the clinical and transition needs of young adults aged 18 to 24.

Verbatim wording from the response
“You were concerned that there is no provision for secure mental health care for young adults aged 18–24 with a similar clinical picture. Whilst there are no dedicated wards for 18 to 24 year olds, there are wards that meet the clinical needs of patients with the same and similar presentation to Miss Overy. There is transition guidance in place which advises that arrangements are made within adult wards to ensure that appropriate patient needs, as highlighted in clinical assessments, are met. Receiving providers should make appropriate plans and extend the services available to aid the transition arrangements for young adults.”

Source location
2014-0535R
Page 4 · response
Published 17 December 2014
Open published response
31 Oct2014
Brighton and Hove
Concerns raised1
1. Failure to complete required transfer documentation and countersignature
This report raised 14 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
  Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  The consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
AI-generated summary

Maureen Annette ELLETT · 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

The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

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 complete required transfer documentation and countersignature
Wider context from the report
“(2) Discussion by the Junior Doctor with the Senior Doctor as to the plan for Mrs. Ellett was brief to the point of transient. No proper detailed plan was formulated. Clues to the patient's condition were missed, probably because the discussion was so brief and the paperwork required for transfer to the short-stay ward, also known as the Clinical Decisions Unit, was signed by the A&E Consultant but neither dated nor timed by him. The plan was incomplete and the counter-signatory of the Senior Nurse with date and time was completely missing. Therefore the transfer should not have taken place. ”
Source location
Maureen Annette ELLETT · 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
Remind consultants and shift leaders to require a detailed management plan and shift-leader confirmation before transferring patients.

Verbatim wording from the response
“2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 31 October 2014
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 consultant’s undated signature on transfer documentation was not relevant to the patient’s clinical care.

Verbatim wording from the response
“2. We believe the A&E consultant’s failure to date and time his signature on the transfer documentation, while not best practice, is not relevant to the clinical care of Mrs Ellett. However, we agree that she should not have been transferred until an appropriately detailed plan for her management had been agreed and summarized in a series of bullet points in the documentation, and the clinical shift leader had confirmed his agreement by signing the proforma. All the consultants and the relevant shift leaders have been reminded of the importance of this aspect of their duties.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 31 October 2014
Open published response
28 Jul2014
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to complete All Wales Inter Hospital Transfer documentation
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

Hope Erin Evans · 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

Hope Erin Evans, a premature baby born at 26 weeks, died from sepsis contributed to by ESBL E. coli contracted in hospital. The report states that the source was likely another baby, although the means of transfer was unknown. Concerns included important patient history not being captured and passed between hospitals, and the failure to complete All Wales Inter Hospital Transfer documentation.

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 complete All Wales Inter Hospital Transfer documentation
Wider context from the report
“2. The All Wales Inter Hospital Transfer documentation was not completed and revision of the documentation should be considered. ”
Source location
Hope Erin Evans · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2014
Norfolk
Concerns raised1
1. Failure to plan patient transfers to another Trust in advance
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.

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

SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · 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

Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

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 plan patient transfers to another Trust in advance
Wider context from the report
“I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust. ”
Source location
SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Jun2014
Manchester South
Concerns raised1
1. Failure of timely coordination and availability for inter-hospital 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.
Actions described in response 2
1. Action
  Require liaison with Clinical Site Coordinators before arranging inter-site transfers to confirm bed availability.
  Stated by Manchester University NHS Foundation TrustStated planned
2. Action
  Continue embedding and refining the inter-site transfer process through ongoing review and small adjustments.
  Stated by Manchester University NHS Foundation TrustStated in progress
AI-generated summary

THOMAS PATRICK MAHER · 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

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

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 of timely coordination and availability for inter-hospital patient transfers
Wider context from the report
“4. On or around the 3rd February, a discussion took place between the treating doctor at Trafford and an orthopaedic specialist at MRI, during which it was agreed that a bed was available at MRI and that Mr Maher would be transferred. The ambulance was ordered to transport him and Mr Maher was taken and placed in the vehicle. In fact it then transpired that there was no bed available so he had to be taken from the vehicle and returned to the ward at Trafford General. In the course of his evidence to me, the consultant Physician stated “we have major problems getting patients transferred to MRI and other hospitals, we frequently have to wait 3 or 4 days for transfer of a patient who should have gone immediately”. He then went on to state that in his opinion the ability to transfer patients between divisions of the same trust should be ‘second to none’ and in fact it is less than adequate. ”
Source location
THOMAS PATRICK MAHER · 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
Require liaison with Clinical Site Coordinators before arranging inter-site transfers to confirm bed availability.

Verbatim wording from the response
“It has been agreed that in future all transfers between sites will not be arranged without liaison with the Clinical Site Coordinators to ensure that this unacceptable situation does not arise again.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 3 · response
Published 5 June 2014
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 embedding and refining the inter-site transfer process through ongoing review and small adjustments.

Verbatim wording from the response
“Trafford Division acknowledges that since implementation of the New Clinical Model in November 2013, there has been a period of significant change and time needed for the new transfer process to be embedded. A transfer policy has been in place since the New Clinical Model was established but adherence to this policy was variable in the early stages. Continuous efforts have been made to ensure that this is fully embedded in practice and we can offer assurance that since the start of this new system there have been 485 patient transfers between the two sites with no instances of patient harm reported as a result. Trafford Division is confident that staff are aware of the transfer policy and that this has been communicated to them. The Division is continually reviewing and making small adjustments to the transfer process in order to make improvements.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 3 · response
Published 5 June 2014
Open published response
17 Apr2014
Plymouth, Torbay & South Devon
Concerns raised2
1. Failure to identify required ambulance type when requesting transfer
2. Unavailability of airway support during time-critical patient transfer for CT
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

Karen Lesley Peters · 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

Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

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 identify required ambulance type when requesting transfer
Wider context from the report
“3. Transfer of time critical patients I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team: (a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required; (b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way. I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard. I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue? I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance? ”
Source location
Karen Lesley Peters · Prevention of Future Deaths report
Page 5 · concerns
Open source report
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 airway support during time-critical patient transfer for CT
Wider context from the report
“2. At 06.15 hours on 29 March, Karen was found to have a GCS of 6. She was sent for an immediate CT Scan and this was completed within 45 minutes, which I found to be commendable. I heard evidence, however, from a ████████ who was the F1 doctor who took Karen to the CT scanner. He told me that no airway support was available to him at that time. He felt exposed and it was plain that Karen was similarly exposed. Fortunately, there were no complications during the course of the Scan, but it is easy to see that in similar circumstances, a problem could develop that the Junior doctor looking after the patient would be unable to resolve. I would be grateful if you could let me have your thoughts as to how you propose to address this difficulty. ”
Source location
Karen Lesley Peters · Prevention of Future Deaths report
Page 4 · concerns
Open source report
14 Apr2014
North East Kent
Concerns raised1
1. Lack of formal handover and transfer of important information between community nursing teams
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Implement a formal process for transferring care between community nursing teams.
  Stated by Kent Community Health NHS Foundation TrustStated completed
2. Action
  Revise transfer-of-care policies and procedures through an established working group.
  Stated by Kent Community Health NHS Foundation TrustStated in progress
3. Action
  Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.
  Stated by Kent Community Health NHS Foundation TrustStated in progress
1. Action
  Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.
  Stated by Kent Community Health NHS Foundation TrustStated planned
AI-generated summary

Winifred Olive DENNIS · 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

Winifred Olive DENNIS died at home on 27 December 2012 after a deterioration in health leading to reduced and ultimately no mobility. She had developed a deep sacral pressure sore, and the inquest recorded bronchopneumonia and the pressure sore as the clinical causes of death. The report identified a concern that information about her previous airflow mattress was not formally handed over when she moved between care settings, potentially reducing the provision of optimum 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 formal handover and transfer of important information between community nursing teams
Wider context from the report
“(1) The evidence was that within Kent Community Health NHS Trust the community nurses are organised into teams dependent upon the GP surgeries that they are covering. As a result, the moving of a patient from her own home to a Care Home, or between Care Homes, can cause her to be transferred from one Community Nursing Team to another, occurred in this instance. Although from the patient's notes would be transfer, the Trust had no formal handover document as such for a patient in these circumstances, and in this instance, the information that at her previous Home she had had the benefit of an airflow mattress was not communicated to the next Home on her move there. Care Homes look to the community nurses for such guidance. (2) In other cases, similar important information not directly of a clinical nature might not be transferred and the chances of optimum care being delivered to a patient might accordingly be reduced. ”
Source location
Winifred Olive DENNIS · 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
Implement a formal process for transferring care between community nursing teams.

Verbatim wording from the response
“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location
2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014
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
Revise transfer-of-care policies and procedures through an established working group.

Verbatim wording from the response
“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location
2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014
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
Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.

Verbatim wording from the response
“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location
2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014
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
Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.

Verbatim wording from the response
“Response A formal process to enable the transfer of care between community nursing teams has been devised. A working group has been established to revise the policies and procedures and monitor through clinical audit all aspects of transfer of care. Work is already underway to improve the documentation associated with transfer to ensure all patients have a full holistic reassessment prior to transfer that clearly documents the patients care needs handed over to the teams responsible for implementing the on-going care. This process ensures continuity of care. Patients’ on-going needs are clearly identified and communicated effectively upon transfer between community nursing teams. The training available to staff for holistic assessment and care planning has been revised and the new programme is now being rolled out.”

Source location
2014-0167-Response-by-Kent-Community-Health-NHS-Trust
Page 1 · response
Published 14 April 2014
Open published response
13 Jan2014
County Durham and Darlington
Concerns raised3
1. Lack of clarity about the circumstances and means for arranging hospital transfers
2. Lack of a system guiding privately funded transfers between hospitals
3. Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers
This report raised 9 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
  Consult with NOMS on prisoners’ access to private healthcare and transfers from NHS care.
  Stated by Department of Health and Social CareStated completed
AI-generated summary

Zeeyad Hamadi · 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

Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

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 the circumstances and means for arranging hospital transfers
Wider context from the report
“(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”
Source location
Zeeyad Hamadi · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 a system guiding privately funded transfers between hospitals
Wider context from the report
“(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”
Source location
Zeeyad Hamadi · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 a formal policy for situations involving privately funded prisoner health care and hospital transfers
Wider context from the report
“(3) There was limited liaison between health care staff in HMP Frankland and medical staff at UHND to monitor the deceased’s medical condition once he had left the prison. When a decision was made by the deceased to seek treatment in London on a private paying basis this information was not speedily communicated to those responsible for health care in HMP Frankland and contact was made by a hospital doctor with a duty governor at the prison who in turn had to refer to the health care manager. Confusion developed as to the basis of the proposed move to Bart’s from UHND; whether this was a prison to prison transfer or whether it was a relocation of the deceased from one hospital to another whilst remaining the responsibility of HMP Frankland. There was confusion over the funding arrangements for this proposal; whether the local NHS would be responsible for the medical treatment or the costs of transport, the form of such transport and/or the costs of bed watch. The brother of the deceased confirmed to different people at different times that he would undertake to be responsible for the costs incurred (subject to a challenge by Judicial review) and it took some time for the issues of funding to be identified before being addressed and resolved. There was a lack of clarity of understanding who would be responsible for what and when, so far as money was concerned and who would have the responsibility for payment in the first place prior to reimbursement by the deceased’s brother. There was no formal policy in place to deal with the situation. There was lack of clarity in the rules that were referred to in evidence as to how and when a convicted prisoner is entitled to private health care as opposed to a prisoner on remand. ”
Source location
Zeeyad Hamadi · 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
Consult with NOMS on prisoners’ access to private healthcare and transfers from NHS care.

Verbatim wording from the response
“Officials have consulted with NOMS and with regard to the issue of whether a prisoner is entitled to use private healthcare, and what happens if they are using NHS services and wish to transfer to the private sector, I can confirm that it is very rare for a prisoner to seek private treatment. There are no national protocols currently in place by which a request for private treatment from a prisoner would be considered.”

Source location
2014-0014-Response-by-Department-of-Health
Page 3 · response
Published 13 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain safe systems of transfer while patients are being transferred

Concerns raised1

Failure to complete transfer documentation between wards

Concerns raised1

Failure to ensure that immediate transfers at age 18 are in the person's best interests

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Failure to complete required transfer documentation and countersignature

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 complete All Wales Inter Hospital Transfer documentation

Concerns raised1

Failure to plan patient transfers to another Trust in advance

Concerns raised1

Failure of timely coordination and availability for inter-hospital patient transfers

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 raised2

Failure to identify required ambulance type when requesting transfer

Unavailability of airway support during time-critical patient transfer for CT

Concerns raised1

Lack of formal handover and transfer of important information between community nursing teams

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.4

Concerns raised3

Lack of clarity about the circumstances and means for arranging hospital transfers

Lack of a system guiding privately funded transfers between hospitals

Lack of a formal policy for situations involving privately funded prisoner health care and hospital transfers

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 3

Actions described in response 1

Respondent positions 1

Actions described in response 2

Actions described in response 4

Actions described in response 1