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
NHS trust66
Executive non-departmental public body15
Healthcare site13
Ministerial department11
Local health board10
Type not available7
Residential care home5
Devolved government4
Executive agency4
Health and care inspectorate3
Independent healthcare provider3
Prison or young offender institution3
Private limited company3
Company limited by guarantee2
Health and social care service regulator2
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.
Nottinghamshire
Concerns raised1
Lack of a system for prioritisation of urgent surgical patients awaiting transfer
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Develop and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Tailor the tracking system to orthopaedic standards and complete its implementation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Discuss implementation of the tracking system with wider specialties for surgical patients.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Worcestershire
Concerns raised1
Absence of a formal, documented handover system between hospital and Neighbourhood Team
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
Essex
Concerns raised1
Failures to organise and coordinate inter-hospital transport
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The transfer delay did not affect the clinical outcome because appropriate care was provided at Basildon Hospital.
Stated by Mid and South Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Urgent transfers are prioritised by the Trust and East of England ambulance service.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Failure to give sufficient weight to continuity of clinical care in transfer decisions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Transfer to Derriford Hospital was correct because urgent assessment was required and it provided the closest prompt access to acute care.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The assessing ambulance crew has paramount responsibility for the clinical decision about a patient's conveyance destination.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Community-based care and transfer to Liskeard were appropriate because there was no urgent need for orthopaedic revision surgery.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Transfers between Liskeard Community Hospital and Derriford Hospital were appropriate and reasonable based on the patient's clinical presentation.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Coventry and Warwickshire
Concerns raised1
Lack of consistent understanding of responsibility for initiating patient transfers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
Stated by The British Transplantation Society and UK Kidney Association (UKKA; formerly the Renal AssociationStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Make UHCW the primary specialist transfer centre and accept all renal patients admitted to GEH, regardless of their parent hospital.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 November 2024.
Action
Operate a daily 11:30am huddle with the Medicine Operational team, including a renal doctor, to identify and prioritise interhospital transfers.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Accept responsibility for recommending the best care location for patients referred to Renal Services.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Stated by University Hospitals Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing consultant-to-consultant transfer arrangements and the renal specialist service-level agreement are considered sufficient for transferring patients when required.
Stated by George Eliot Hospital NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Lack of shared understanding and expectations between medical teams about how Patient Pass operates
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Convene a cross-Trust working group, review the incident, and agree actions to improve understanding and operation of Patient Pass.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Finalise and circulate a communications guide clarifying Patient Pass purposes and referrer and receiver responsibilities across Greater Manchester hospitals.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2024.
Action
Add a new-user Patient Pass screen explaining user responsibilities and requiring acceptance before system access.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.
Action
Create, consult on, and circulate a seven-minute Greater Manchester briefing sharing learning on applying transfer policies and using Patient Pass.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2024.
Dorset
Concerns raised1
Lack of national guidance for healthcare handover to receiving prisons
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Lack of a transfer protocol or pathway for transition from childhood to adulthood
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.5
Action
Operate an agreed cross-trust transition pathway covering records, individual plans, transfer information and attendance at the first adult appointment.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Provide specialist transition-team support, including multidisciplinary discussions and assistance with initial adult appointments or inpatient ward visits for young people with complex needs.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Run a monthly transition clinic for hydrocephalus patients aged 14 and over, with extended appointments covering clinical review and transition preparation.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Formalise the transition process in a written pathway clarifying how young people with shunts move from children’s to adult services.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 April 2024.
Action
Participate in the regional innovator project to standardise developmentally appropriate transition care, including defined roles, staff training, personalised plans and patient tracking.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine shunt reviews are not clinically required after transition; patients remain able to seek advice about symptoms or concerns.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised1
Failure to communicate relevant clinical information before transfer
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Suffolk
Concerns raised1
Lack of clarity in the categorisation process for urgent inter-hospital transfers
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Maintain and update the national framework for inter-facility ambulance transfers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Review the National Framework for Inter-Facility Transfers with NHS England in light of the death.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
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Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
