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.

4 Jan2024
East Sussex
Concerns raised1
1. Inadequate information in healthcare paperwork about a sick prisoner’s condition
This report raised 11 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

Stephen COSTER · 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

Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

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
Inadequate information in healthcare paperwork about a sick prisoner’s condition
Wider context from the report
“e. There was a breakdown in communication between healthcare staff and prison staff regarding transferring a sick prisoner to hospital as an emergency. Further, there was inadequate information included on the paperwork prepared by healthcare staff about Stephen Coster’s condition resulting in delay in arranging for his urgent escort and transfer to hospital. ”
Source location
Stephen COSTER · Prevention of Future Deaths report
Page 1 · concerns
Open source report
7 Dec2023
Inner North London
Concerns raised2
1. Failure to transfer care to the appropriate clinical specialty
2. Delays and confusion in inter-hospital transfer coordination
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
  Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
2. Action
  Review processes for allocating the named consultant, agreeing joint care, and escalating disagreements about care ownership.
  Stated by University College London Hospitals NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  UCLH disputes that gastroenterology had agreed to take over care, stating that specialist gastroenterology teams reviewed the patient instead.
  Stated by University College London Hospitals NHS Foundation TrustDisputes the concern
1. Position
  The transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.
  Stated by University College London Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Sarah CHAPPELL · 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

Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.

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 care to the appropriate clinical specialty
Wider context from the report
“2. From at least 16 June 2023, the consultant urology surgeon in charge of Ms Chappell’s care was very firmly of the view that he was not the best clinician to fulfil this role. He had long since correctly determined that she had not sustained a ruptured bladder, and thus considered that her care belonged with the gastroenterologists or the general surgeons. Despite the agreement on 16 June of the gastroenterology clinical director that Ms Chappell’s care should be led by the gastroenterologists, they had not taken over her care by the time of her death, and there had not even been a conversation between the gastroenterology and general surgery consultants about the transfer of care. ”
Source location
Sarah CHAPPELL · 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
Delays and confusion in inter-hospital transfer coordination
Wider context from the report
“1. There was a ten day delay in Ms Chappell’s transfer from the Princess Royal Hospital to UCLH. I was told that this might have been because of a lack of beds, but it might also have been because of confusion about which UCLH site was the accepting surgeon’s preferred destination, a confusion that was understood at the time by the Princess Royal to be a rejection of the transfer. ”
Source location
Sarah CHAPPELL · 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
Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.

Verbatim wording from the response
“Recognising that there was confusion between PRUH and UCLH relating to transfer we will develop a referral form for urology by May 2024 to improve documentation around the reason for transfer and agreed decisions to inform the plan of care. This will be led by the clinical lead for urology and will mirror some of our best practice referrals such as in the thoracic service.”

Source location
Response from University College London Hospitals
Page 3 · response
Published 19 December 2023
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
Review processes for allocating the named consultant, agreeing joint care, and escalating disagreements about care ownership.

Verbatim wording from the response
“We completely recognise that clearer processes both around joint care and escalation of decisions on ownership of care if there are disagreements are required. We will review our processes for allocating the named consultant in charge, agreeing joint care and escalation processes when there is disagreement over the named consultant by May 2024.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 19 December 2023
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
UCLH disputes that gastroenterology had agreed to take over care, stating that specialist gastroenterology teams reviewed the patient instead.

Verbatim wording from the response
“For clarification, the clinical director for gastroenterology was not involved in discussions relating to Ms Chappell’s care at UCLH: this was undertaken by the clinical lead for gastroenterology.”

Source location
Response from University College London Hospitals
Page 4 · response
Published 19 December 2023
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 delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.

Verbatim wording from the response
“Ms Chappell was transferred to UCLH as an emergency referral from PRUH on 1st June 2023, as the team there believed she had suffered a perforation of her neobladder. She had been discussed by the PRUH team with a urology consultant on 22 May 2023 and accepted for transfer, however there were no available beds at the time at UCLH. PRUH appear to have organised Ms Chappell’s transfer to the UCLH Emergency Department without confirming with the Urology team at UCLH and Ms Chappell was subsequently admitted to a surgical ward (T14 north) when they had a bed available. Ms Chappell was then transferred to T14 Acute Surgical Unit on the evening of 1st June 2023.”

Source location
Response from University College London Hospitals
Page 3 · response
Published 19 December 2023
Open published response
7 Nov2023
Somerset
Concerns raised1
1. Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis
This report raised 6 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

Irene Joy White · 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

Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.

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 obtain and clarify discharging-hospital information about care needs and thromboprophylaxis
Wider context from the report
“I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
Source location
Irene Joy White · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Oct2023
Nottinghamshire
Concerns raised3
1. Failure to ensure all involved have the information required to contribute effectively to the transfer process
2. Failure to ensure smooth transitions between care facilities during discharge or transfer
3. Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities
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
  Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.
  Stated by Nottinghamshire County CouncilStated completed
2. Action
  Hold weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.
  Stated by Nottinghamshire County CouncilStated completed
AI-generated summary

Janet Irene SPENCER · 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

Janet Irene Spencer suffered an unwitnessed fall in her assisted living accommodation on 30 August 2022, sustaining a traumatic acute subdural haematoma. She was treated in hospital and placed on end-of-life care, but did not recover and died some 13 days later; underlying ischaemic heart disease contributed to, but did not directly cause, her death. The report identified concerns about inadequate and outdated risk assessments and care plans during discharge or transfer, and insufficient information-sharing to support smooth transfers between care facilities.

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 all involved have the information required to contribute effectively to the transfer process
Wider context from the report
“2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. ”
Source location
Janet Irene SPENCER · 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
Failure to ensure smooth transitions between care facilities during discharge or transfer
Wider context from the report
“2. The systems in place in respect of discharge to assess patients do not appear to ensure a smooth transition between care facilities, especially when transfers are arranged at pace. In particular, they do not appear to ensure that all involved have the information they require to contribute effectively to the transfer process. ”
Source location
Janet Irene SPENCER · 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
Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities
Wider context from the report
“1. The systems in place in respect of discharge to assess patients do not appear to ensure patients are discharged or transferred between care facilities with an adequate and up to date risk assessment and care plan in place. ”
Source location
Janet Irene SPENCER · 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
Implement and use a referral and assessment process for Assessment Flat admissions, recording care needs, risks and medical information and sharing them with providers.

Verbatim wording from the response
“11. The LA recognises that improvements have been required in the clear and accurate sharing of up-to-date information for admission to the Assessment Flats, as illustrated by Mrs Spencer’s situation. To ensure that the risk of any future breakdown in communication is mitigated, a new process and referral / assessment form has been implemented for all people moving into Assessment Flat accommodation. This process is for hospital and community admissions into”

Source location
Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023
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
Hold weekly Transfer of Care Hub audits and reflective discussions about hospital discharges and required improvements.

Verbatim wording from the response
“9. At a more operational level, the Transfer of Care Hubs hold weekly audits and reflective discussions of hospital discharges that have gone well or where improvements are required.”

Source location
Response from Nottinghamshire County Council
Page 2 · response
Published 29 December 2023
Open published response
14 Sep2023
North Wales (East and Central)
Concerns raised1
1. Failure to provide a finalised and widely shared transfer-of-care process
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 1
1. Action
  Progress the revised Transfer and Discharge of Care Protocol through Health Board ratification.
  Stated by Betsi Cadwaladr University LHBStated in progress
AI-generated summary

Richard Geraint Griffiths · 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

Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.

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 a finalised and widely shared transfer-of-care process
Wider context from the report
“b. The Health Board’s Transfer of Care document at the time the transfer occurred did not include any detail or process as to how the transfer should occur. The amended policy has still not been finalised and there remains a concern that deaths will continue to occur if the process is not finalised and shared widely within the Health Board to staff. ”
Source location
Richard Geraint Griffiths · 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
Progress the revised Transfer and Discharge of Care Protocol through Health Board ratification.

Verbatim wording from the response
“The Transfer and Discharge of Care Protocol has been revised to include explicit guidance relating to transfers of care between community teams. This includes the steps to be taken by the care coordinator, supporting administrative staff and the single point of access service (SPOA). Progression of this protocol through the Health Board ratification process is being led by the MH&LD Deputy Director of Nursing and progress is overseen by the MH&LD Policy and Procedure Group. The revised protocol is due at MH&LD Policy and Procedure Group in December 2023 after which it will progress through the Health Board’s revised ratification process. I anticipate that the protocol will be ratified by the end of January 2024.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023
Open published response
13 Sep2023
Norfolk
Concerns raised1
1. Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
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 8
1. Action
  Maintain additional ambulance capacity funded to expand capacity and improve response times.
  Stated by Department of Health and Social CareStated completed
2. Action
  Deliver new ambulances and specialist mental health vehicles.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
  Stated by Spire Healthcare LimitedStated completed
1. Action
  Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
  Stated by Spire Healthcare LimitedStated completed
2. Action
  Complete and register a group-wide risk assessment addressing ambulance transfer delays.
  Stated by Spire Healthcare LimitedStated completed
3. Action
  Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
  Stated by Spire Healthcare LimitedStated in progress
4. Action
  Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
  Stated by Spire Healthcare LimitedStated completed
5. Action
  Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
  Stated by Spire Healthcare LimitedStated in progress
Respondent positions 1
1. Position
  Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
  Stated by Spire Healthcare LimitedUnable to act
AI-generated summary

Geoffrey Douglas HOAD · 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

Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.

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 inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
Wider context from the report
“9. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital. 10. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result. 11. At the inquest Spire Norwich Hospital placed great reliance on now being part of an Interfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers. 12. This concern has been raised at previous inquest. ”
Source location
Geoffrey Douglas HOAD · 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
Maintain additional ambulance capacity funded to expand capacity and improve response times.

Verbatim wording from the response
“Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
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
Deliver new ambulances and specialist mental health vehicles.

Verbatim wording from the response
“Your report highlights that EEAST were under high demand at the time of the incident. A primary aim of our delivery plan is to boost ambulance capacity. Ambulance services received £200 million of additional funding in 2023/24 to expand capacity and improve response times, and we are maintaining this additional capacity in 2024/25. This is alongside the delivery of new ambulances and specialist mental health vehicles. With more ambulances on the road, patients will receive the treatment they need more swiftly.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 15 September 2023
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
Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.

Verbatim wording from the response
“Action 2 Review of all transfers of care from SNH to Norfolk and Norwich Hospital in the period October 2021 to October 2023.”

Source location
Response from Spire Healthcare
Page 5 · response
Published 15 September 2023
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
Complete and register a hospital-level risk assessment addressing ambulance transfer delays.

Verbatim wording from the response
“24. Spire Healthcare is acutely aware of the demands placed on NHS ambulance services and the resulting delays in ambulance response times.”

Source location
Response from Spire Healthcare
Page 8 · response
Published 15 September 2023
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
Complete and register a group-wide risk assessment addressing ambulance transfer delays.

Verbatim wording from the response
“26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.”

Source location
Response from Spire Healthcare
Page 8 · response
Published 15 September 2023
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
Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.

Verbatim wording from the response
“26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.”

Source location
Response from Spire Healthcare
Page 8 · response
Published 15 September 2023
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
Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.

Verbatim wording from the response
“29. The Inter Facility Transfer Group (IFTG) led by NNUH was set up to facilitate the inter facility transfer of unplanned emergency patients in the local area. Its first meeting took place in June 2022. As at October 2023, the membership of the group comprises representatives from the following organisations:”

Source location
Response from Spire Healthcare
Page 9 · response
Published 15 September 2023
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 working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.

Verbatim wording from the response
“31. Following the inquest into the death of Mr Hoad and the subsequent concerns raised by HM Coroner, SNH raised concerns to the chair of the Interfacility Transfer Group that EEAST’s PFD witness had stated in court that the work of the IFTG was not expected to reduce delays in interhospital transfers. The chair of the IFTG met with EEAST’s Head of Patient Safety and it was agreed that, as of 02.10.23, they (EEAST’s PFD witness at the inquest) would join the IFTG in order that they are fully aware of the purpose of the group and involved in all associated actions. The intended benefits of the IFTG are as follows:”

Source location
Response from Spire Healthcare
Page 9 · response
Published 15 September 2023
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
Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.

Verbatim wording from the response
“26. Spire Healthcare has completed a group wide risk assessment in respect of ambulance transfer delays and this risk is recorded on the national risk register. The risk is regularly reviewed and all actions to reduce the risk are considered and recorded. One such action is to consider the use of private ambulance services to support interfacility transfers. This is addressed in more detail below.”

Source location
Response from Spire Healthcare
Page 8 · response
Published 15 September 2023
Open published response
8 Sep2023
Avon
Concerns raised1
1. Failure of hospital medication systems to exchange information, requiring manual transcription during ICU transfers
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 6
1. Action
  Apply a doctor’s second check when prescribers complete ward drug charts.
  Stated by Bristol NHS Foundation TrustStated completed
2. Action
  Provide routine training for junior and rotational ward pharmacists receiving intensive-care step-down patients.
  Stated by Bristol NHS Foundation TrustStated completed
3. Action
  Provide a designated quiet space for medication transcription.
  Stated by Bristol NHS Foundation TrustStated completed
1. Action
  Participate in regional auditing to share learning and identify opportunities to reduce medication errors during intensive-care step-down.
  Stated by Bristol NHS Foundation TrustStated completed
2. Action
  Implement Careflow Medicines Management across most clinical areas to standardise prescribing and support electronic medicines reconciliation and medication-error controls.
  Stated by Bristol NHS Foundation TrustStated in progress
3. Action
  Invest in additional adult intensive-care pharmacy staff to provide trained-individual medicines reconciliation five days weekly and weekend safety-net reviews.
  Stated by Bristol NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  A unified electronic prescribing system cannot be introduced because ward and intensive-care systems have incompatible specialised requirements.
  Stated by Bristol NHS Foundation TrustUnable to act
1. Position
  Interoperability between prescribing systems cannot be achieved because it requires technical input from competing external providers outside the Trust’s control.
  Stated by Bristol NHS Foundation TrustUnable to act
AI-generated summary

Ms Cherry Lynne GARLAND · 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

Ms Cherry Lynne GARLAND died on 11 October 2022 in the Bristol Royal Infirmary from sepsis and right-sided heart failure after cardiac treatment, vascular injury, Covid and pneumonia. During her transfer from the Cardiac High Dependency Unit to the Cardiac Ward, a transcription error omitted antibiotics from her medication list, although the evidence accepted was that discontinuing them would have been reasonable at that time. The report raises concern that incompatible medication systems, manual transcription and insufficient pharmacist capacity create a known risk of future medication errors and deaths.

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 hospital medication systems to exchange information, requiring manual transcription during ICU transfers
Wider context from the report
“My concerns • I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that: - “... Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours - The ICU retains lists of its patients’ medication on a computerised/electronic system - The rest of the wards in the hospital do not operate the same system - The available systems do not speak to each other (to put it in somewhat colloquial terms) - Efforts to address that problem have proved fruitless - As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list - With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed daily]” (Coroner’s comment: for obvious reasons this creates enormous potential for human error) - There are a limited number of people who can prescribe (and are therefore able to perform this task); in critical care they are the same people who are responsible for providing care - “We really need a second check… funding for more pharmacists… as a Trust we’re falling short of ICU national standards for years in terms of the number of pharmacists per bed and medicines reconciliation” - “I spoke to the Chief Pharmaceutical Officer – he has submitted 5 proposals in the last 7 years to try to get the deficit funded… [without success]” In summary, my view is that the circumstances currently in place create a very real (and known) risk that transcription errors will continue to occur. This in turn endangers patients, and creates a risk that people will die in the future as a result of such errors. It is, sadly, very easy to envisage circumstances in which a patient might not receive essential medication at all, might receive the wrong dose of the medication they need, or might receive the wrong medication altogether, because of a transcription error. In my opinion there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you. ”
Source location
Ms Cherry Lynne GARLAND · 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
Apply a doctor’s second check when prescribers complete ward drug charts.

Verbatim wording from the response
“Actions already in place to reduce the risk of transcription errors between ITU and the wards:”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 3 · response
Published 14 September 2023
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
Provide routine training for junior and rotational ward pharmacists receiving intensive-care step-down patients.

Verbatim wording from the response
“Actions already in place to reduce the risk of transcription errors between ITU and the wards:”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 3 · response
Published 14 September 2023
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
Provide a designated quiet space for medication transcription.

Verbatim wording from the response
“Actions already in place to reduce the risk of transcription errors between ITU and the wards:”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 3 · response
Published 14 September 2023
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
Participate in regional auditing to share learning and identify opportunities to reduce medication errors during intensive-care step-down.

Verbatim wording from the response
“Actions already in place to reduce the risk of transcription errors between ITU and the wards:”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 3 · response
Published 14 September 2023
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 Careflow Medicines Management across most clinical areas to standardise prescribing and support electronic medicines reconciliation and medication-error controls.

Verbatim wording from the response
“For patients in the ward areas of our hospitals, medicines are currently prescribed using paper drug charts. A Trust-wide system for electronic prescribing and medicines administration, Careflow Medicines Management (CMM), for ward based patients is currently being implemented across”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 1 · response
Published 14 September 2023
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
Invest in additional adult intensive-care pharmacy staff to provide trained-individual medicines reconciliation five days weekly and weekend safety-net reviews.

Verbatim wording from the response
“• You heard in evidence that proposals for additional resource in Pharmacy were presented but, regrettably, there were competing proposals from higher risk areas, which the Trust had to prioritise. I asked the Chief Medical Officer to oversee a review of the funding requests, and entries on the Trust’s risk register, to provide further assurance around this. I confirm that the Trust will invest in additional pharmacy staff for adult ITU to ensure all medicines reconciliation at step down is completed by a suitably trained individual. This will provide a pharmacy medicines reconciliation five days a week. In addition, this investment will provide a safety net review of weekend medicines reconciliation previously undertaken by doctors and advanced nurse practitioners at the weekend at the time of transfer out of ITU.”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 3 · response
Published 14 September 2023
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 unified electronic prescribing system cannot be introduced because ward and intensive-care systems have incompatible specialised requirements.

Verbatim wording from the response
“In addressing transcription challenges within the different clinical areas of UHBW, it may seem desirable to have a unified prescribing system. However, it’s important to acknowledge that the Electronic Patient Record system used for ward-based patients would not be suitable for use on ITU given the specialised requirements of the Intensive Care system. This challenge is not unique to UHBW; across the NHS, different clinical areas, including ITU, maternity, and pathology, often operate with disparate systems due to their complex, individual requirements.”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 2 · response
Published 14 September 2023
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
Interoperability between prescribing systems cannot be achieved because it requires technical input from competing external providers outside the Trust’s control.

Verbatim wording from the response
“In addition, achieving interoperability between the two systems would require extensive technical input from and between the two external competing commercial providers, which would be outside of the Trust’s control.”

Source location
Response from University Hospitals Bristol and Weston NHS Foundation Trust
Page 2 · response
Published 14 September 2023
Open published response
14 Jul2023
Blackpool and the Fylde
Concerns raised1
1. Failure to check care information handed over during hospital transfers
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

Mr Terence Burns · 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 Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during 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 check care information handed over during hospital transfers
Wider context from the report
“Furthermore, I was concerned that the oral evidence that I heard at the inquest, established that the documents handed over to North West Ambulance Services when Mr Burns was taken to hospital, were not checked. When Mr Burns was taken to hospital, it could not be ascertained what information was sent with Mr Burns to enable the hospital to meet his care needs. ”
Source location
Mr Terence Burns · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 May2023
Derby and Derbyshire
Concerns raised2
1. Inadequate handover of treatment plans during transfer of care
2. Failure to identify non-receipt of prescribed tinzaparin during transfer of care
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

Jessica Hodgkinson · 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

Jessica Hodgkinson died on 14 May 2021 at Chesterfield Royal Hospital shortly after giving birth, following a pulmonary embolism arising from a deep vein thrombosis and acute anaphylaxis of unknown cause. The inquest identified failures to communicate and follow up the plan for prophylactic tinzaparin until birth, and concerns about consideration and documentation of her Klippel-Trenaunay Syndrome during pregnancy.

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
Inadequate handover of treatment plans during transfer of care
Wider context from the report
“(2) I heard evidence that there was no communication to the team in Sheffield that Jess’ consultant in Chesterfield intended that she should continue to receive tinzaparin until birth. Therefore, when Jess was discharged from Sheffield on 26 April 2021, she was not given tinzaparin because the team in Sheffield were unaware of this plan. I am concerned, therefore, about the quality and adequacy of the information handed over to Sheffield at the point of Jess being transferred into their care. ”
Source location
Jessica Hodgkinson · 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
Failure to identify non-receipt of prescribed tinzaparin during transfer of care
Wider context from the report
“(1) I heard evidence from Jess’ consultant that she intended that tinzaparin would be taken by Jess up until birth. When Jess was discharged from Sheffield back into the care of Chesterfield, nobody in Chesterfield identified that Jess was not receiving the tinzaparin which the consultant told the inquest ought to have been in place until birth. ”
Source location
Jessica Hodgkinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Mar2023
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Lack of prompt and secure delivery of radiology reports during interhospital 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 3
1. Action
  Send unreported radiology reports by email and confirm safe receipt by telephone when patients leave emergency departments.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Include the unreported-report process in major trauma standard operating procedures and checklists.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Provide Trauma Group oversight and ongoing audit of the new unreported-report process.
  Stated by Betsi Cadwaladr University LHBStated planned
AI-generated summary

Sara Anest 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

Sara Anest Jones died at Royal Stoke University Hospital on 2 April 2021 from complications of a bowel injury sustained in a road traffic collision on 30 March 2021. The concerns included delayed and unconfirmed delivery of a CT radiology report between hospitals, failure to follow up signs of possible bowel injury, and the absence of a protocol for prompt and secure delivery of radiology reports in such circumstances.

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 prompt and secure delivery of radiology reports during interhospital transfers
Wider context from the report
“A CT scan of the deceased was undertaken at Ysbyty Gwynedd late on the evening of 30th March 2021. The deceased was then transferred to the Royal Stoke University Hospital, Stoke-on-Trent by air ambulance before the radiologist's report on the CT scan was available. Because of this the patient was transferred without the radiologist's report. The radiologist's report became available shortly before 1:00am on 31st March 2021, but was not sent to the Royal Stoke University Hospital until 5:35am that day. It was not clear that safe receipt of the report in Stoke-on-Trent was ever confirmed. Doctors in Stoke-on-Trent then failed to follow up on signs of a possible bowel injury which were indicated in the radiologist's report on the CT scan. During the inquest I was told that the circumstances of this case were unusual and that there was not a protocol in place to ensure the prompt and secure delivery of radiology reports in circumstances like this. ”
Source location
Sara Anest JONES · 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
Send unreported radiology reports by email and confirm safe receipt by telephone when patients leave emergency departments.

Verbatim wording from the response
“We have now established a process that if a patient leaves our emergency departments without a report, which is very rare, then the report will be sent by email and its safe receipt will be confirmed by telephone.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023
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
Include the unreported-report process in major trauma standard operating procedures and checklists.

Verbatim wording from the response
“This process is being included in our major trauma standard operating procedure and checklists by the end of May 2023 by our Trauma Network Manager. This will ensure staff are clear on the actions they need to take.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023
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
Provide Trauma Group oversight and ongoing audit of the new unreported-report process.

Verbatim wording from the response
“All trauma transfers are discussed and reviewed at our Trauma Group, so this group will have oversight of this new procedure and will ensure this new process is subject to ongoing audit to give assurance.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 20 April 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate information in healthcare paperwork about a sick prisoner’s condition

Concerns raised2

Failure to transfer care to the appropriate clinical specialty

Delays and confusion in inter-hospital transfer coordination

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis

Concerns raised3

Failure to ensure all involved have the information required to contribute effectively to the transfer process

Failure to ensure smooth transitions between care facilities during discharge or transfer

Failure to ensure adequate and up-to-date risk assessments and care plans during discharge or transfer between care facilities

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 a finalised and widely shared transfer-of-care process

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

Concerns raised1

Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of hospital medication systems to exchange information, requiring manual transcription during ICU 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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 2

Respondent positions 2

Actions described in response 2

Actions described in response 1

Actions described in response 8

Respondent positions 1

Actions described in response 6

Respondent positions 2