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

Distinct published reports

Individual concerns
131

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
151

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England14
Department of Health and Social Care10
University Hospitals Sussex NHS Foundation Trust5
Betsi Cadwaladr University LHB4
HM Prison and Probation Service4
Manchester University NHS Foundation Trust4
Swansea Bay University Local Health Board4
University Hospitals of Derby and Burton NHS Foundation Trust4
Welsh Government4
Greater Manchester Mental Health NHS Foundation Trust3
Healthcare Inspectorate Wales3
Stockport NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust2
Bedfordshire Hospitals NHS Foundation Trust2

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.

  1. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · 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

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    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 prisoner transfer documentation accurately

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · 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

    Issue and check improved guidance for sergeants on completing, timing and signing off Prisoner Escort forms.

    Verbatim wording from the response

    “Since your observations we have put out improved guidance on completion of the PER form to sergeants which include what to record, when it is to be done and how it is to be signed off. This has been extensively checked and has led to improvements in standards.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 6 January 2014

    Open published response

  2. Central Lincolnshire

    AI-generated summary

    Susan Jill Hammond · Prevention of Future Deaths report

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

    Report summary

    Susan Jill Hammond, who had a known penicillin allergy, was admitted to hospital after becoming ill and was administered intravenous Augmentin despite allergy warnings. She suffered a cardiac arrest and died on 3 July 2009. The principal concerns were that allergy warnings were not sufficiently noticed and that the handover between departments did not communicate her penicillin allergy.

    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 effective allergy information handover during transfers from A&E to EAU

    Wider context from the report

    “(2) It appears that when Mrs Hammond transferred from the A&E unit to the EAU she was accompanied by a nurse who had little knowledge of Mrs Hammond's condition. As a consequence no discussion took place at the handover regarding the nature of Mrs Hammond's allergy to penicillin. It is felt that the nurse who had cared for Mrs Hammond in the A&E department had personally accompanied her to the EAU this would have enabled a more productive handover and would have given an opportunity for discussion regarding the allergy. Although I appreciate there may be practical difficulties I would suggest that in future when a patient is transferred care for the patient in A&E should always accompany the patient to the EAU department in order that constructive handover can take place. ”

    Source location

    Susan Jill Hammond · 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

    Use the SBAR handover tool for transfers from A&E to MEAU, including an allergy prompt.

    Verbatim wording from the response

    “2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR. This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating key points of information. Within the background section is a prompt sheet for highlighting allergies. SBAR has been found to improve communications between members in different clinical areas ie A&E vs wards.”

    Source location

    2013-0286-Response-by-United-Lincolnshire-Hospitals-NHS
    Page 2 · response
    Published 4 November 2013

    Open published response

  3. Manchester South

    AI-generated summary

    Margaret Theresa CORRIGAN · 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

    Margaret Theresa Corrigan fell at home on 18 January 2013 and fractured her odontoid peg; the inquest concluded that her death was accidental and recorded medical causes including infarction, vertebral artery dissection, peg fracture and Clostridium Difficile infection. Concerns included ineffective communication, failure to diagnose the fracture promptly, failure to transfer her to a medical team when appropriate, and issuing an outpatient orthopaedic appointment while she was an inpatient.

    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 with medical problems from orthopaedic wards to medical teams

    Wider context from the report

    “3. The patient remained on the orthopaedic ward when she was suffering at that stage from medical problems and ought properly to have been transferred to a medical team. ”

    Source location

    Margaret Theresa CORRIGAN · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026