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. Avon

    AI-generated summary

    Rebecca Jay ROMERO · 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 Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.

    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 a clear documented process for in-patient transfers

    Wider context from the report

    “(1) In this case there was confusion as to whether on an in-patient transfer there should be a Form 2 to go alongside the Form 1 procedure. As well as clarifying this process with all providers concerned consideration should be given that a clear documented process is put in place for in-patient transfers so that all those involved understand clearly the situation and the decision made in relation to the patient. ”

    Source location

    Rebecca Jay ROMERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Southampton and New Forest

    AI-generated summary

    Owen Richard Widlake · 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

    Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.

    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 transfer policy and escalation indicators for tertiary assistance

    Wider context from the report

    “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff. 2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph. 3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN ii) a lack of empowerment indicating a lack of leadership. 4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves. 5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this. 6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm. 7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover. ”

    Source location

    Owen Richard Widlake · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Gloucestershire

    AI-generated summary

    Susan Ann Smalley · 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 Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.

    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 appropriately expedite urgent emergency transfers between hospitals

    Wider context from the report

    “3. When urgent emergency transfers are requested between hospitals, how they are appropriately expedited. ”

    Source location

    Susan Ann Smalley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester West

    AI-generated summary

    Ruth Thompson · 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

    Ruth Thompson became unwell in Italy on 14 April 2017 after suffering a dissecting aortic aneurysm and underwent surgery, but subsequently sustained a pontine brain infarction and developed pressure sores during prolonged immobility. She was repatriated to the United Kingdom, entered end-of-life care on 30 May 2017, and died on 31 May 2017. The substantive concerns included inadequate communication and transfer documentation, lack of proper or informed consent, and insufficient clinical information being provided to UK clinicians, causing delay and uncertainty in treatment and 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

    Failure to ensure effective communication during transfer

    Wider context from the report

    “1. Whilst the family and next of kin accepted that medical discharge from the Ospedale Monaldi and a decision for transfer was made on an assumption that the deceased was medically fit for transfer, the evidence revealed that:- a. In fact, the deceased died within 16 days of repatriation having survived for over a month in hospital in Italy. b. The assurances that the transfer team could speak English and communicate with the deceased at times, the deceased was accompanied by a German clinician with limited English communication and inadequate transfer notes in fact the United Kingdom. c. No proper or informed consent was obtained for the transfer as the evidence suggested that very little information as to the condition and care plan of the deceased had been communicated to the deceased. ”

    Source location

    Ruth Thompson · 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 provide adequate handover documentation for transferred patients

    Wider context from the report

    “2. On her transfer to the United Kingdom, clinicians within the Accident & Emergency Department at the Royal Bolton Hospital were only supplied with two sheets of information from the hospital, written in Italian, which required doctors to use Google Translate, written attempt to interpret that document. The documentation was inadequate and not fit for purpose in that it failed to note or provide basic handover information including:- a. Operative details; b. Interventional treatment and observations; c. Ongoing prescribed medication; d. Recent test results; e. Identification of investigative procedures and their results; f. Treatment plan following discharge; ”

    Source location

    Ruth Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. South Wales Central

    AI-generated summary

    Khuong Lam · 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

    Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.

    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 inform the responsible clinician of ward transfers

    Wider context from the report

    “(3) ████████ the RC told the inquest that if he had been made aware of Khuong Lam’s transfer to PICU he could have reviewed him and decided whether Section 17 leave was still appropriate. The Coroner is concerned that the good practice now adopted by Cardiff Health Board should be replicated across Wales i.e. that the RC be informed of any transfer between wards; that Section 17 leave is reviewed on a transfer (and especially to PICU); and to consider further the number of escorts required for any Section 17 leave. ”

    Source location

    Khuong Lam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Katherine Anne Derbyshire · 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

    Katherine Anne Derbyshire, who had end stage chronic kidney disease, was admitted on 12 November 2016 after compromised dialysis function and a presumed blockage and infection of her peritoneal catheter. She deteriorated while awaiting transfer for ongoing dialysis, became unfit for transfer, and died on 21 November 2016 after palliative end-of-life medication was prescribed. The concerns included the failure to transfer her, delays in considering temporary dialysis, and inadequate communication and contingency planning between the two hospitals.

    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 triage clinical needs to effect timely transfer

    Wider context from the report

    “The deceased was last dialysed at her care home residence on the 4th November 2016 before being admitted as an in-patient at the Royal Albert Edward Infirmary on the 12th November 2016 and correctly assessed as requiring transfer for ongoing dialysis treatment at the Salford Royal Infirmary. However:- a. No transfer to Salford Royal Infirmary, in fact, took place; b. By the time a bed had become available on the 20th November 2016, the condition of the deceased had deteriorated to the extent that transfer could not take place and she was too unwell to tolerate alternative short term dialysis treatment that could be offered at the Royal Albert Edward Infirmary; c. Whilst there was evidence of an active plan of management in the treatment and care of the patient as between the two hospitals, that plan did not provide for action to be taken in the event of the deterioration of the patient as observed in the circumstances of this case; 2. At the Royal Albert Edward Infirmary it would have been possible to consider haemofiltration as a temporary measure, the evidence suggested that: a. This possible alternative was not considered earlier; b. The reason for the deferment of an alternative temporary dialysis at Royal Albert Edward Infirmary was the expectation of a bed becoming available at Salford Royal Infirmary, but there was no evidence that the clinical needs of the patient had been triaged in a manner that effected transfer at an appropriate stage of her treatment and care; c. The quality of communication between the 14th-20th November 2016 raises a fundamental issue of concern in the appropriateness of her treatment and care in light of the fact that the patient was last dialysed on the 4th November 2016. d. There was no evidence received at the Inquest as to when the Royal Albert Edward Infirmary was informed by the Salford Royal Infirmary that a bed was or would have been available for the patient; 3. Accordingly, the case raises issues as to the nature and extent of communication between the two hospitals and the management of patients admitted at Royal Albert Edward Infirmary requiring ongoing dialysis treatment and care. ”

    Source location

    Katherine Anne Derbyshire · 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 implement an inter-hospital electronic referral system with standardised guidance, safety prompts, responsibility assignment and documented telephone referrals.

    Verbatim wording from the response

    “Electronic Referral Pathways SRFT are developing an inter-hospital online referral system which aims to standardise advice and guidance as well as providing prompts for specific information. The system will automate the following:”

    Source location

    2017-0199-Response-by-Salford-Royal-NHS-Trust
    Page 2 · response
    Published 28 July 2017

    Open published response

  7. Manchester City

    AI-generated summary

    Name not published · 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

    A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.

    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 completion or handover and documentation of outstanding A & E investigations

    Wider context from the report

    “2. Ensuring all investigations/assessments are completed before a patient leaves A & E and ensuring an appropriate handover. It is appreciated that it will not be possible for all investigations and tests to be performed before a patient leaves the A & E department but if that is the case then the receiving ward should be informed and there should be a clear documented audit trail so it is clear what is outstanding. ”

    Source location

    Name not published · 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

    Lack of a clear handover and review process for transfer to AMU

    Wider context from the report

    “3. Transfer and hand over of a patient to AMU from A & E. There was no clear hand over process and review when the deceased arrived on the AMU. It would seem sensible that a Senior Nurse/Sister be informed and can then ensure appropriate care is given. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  8. Liverpool and the Wirral

    AI-generated summary

    Linsay Bushell · 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

    Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

    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-organisational transfer arrangements for patients who are not stable

    Wider context from the report

    “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area. The Jury found: Para 3 1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital. 2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014. 3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation. 4. Linsay put herself in the position in which she was found however her intention was unclear. 5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder. 6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death. 7. The risk was managed adequately and effectively during Linsay's period as an in-patient. 8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made. a. In the Trust Position Statement Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them. 2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015. 3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material. 4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest. 5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity. 6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism. It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment. a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour. b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism. c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism. 7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust. 8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows: a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub. b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour. c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient. d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases. e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package. 9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation. 10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided. 11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels. 12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better. b. In the implementation of Lessons learnt the Trust further accepts 1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay". a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:- b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan. c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay. d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all. e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear. f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan. g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time. h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together. i. Poor coordination of referral to a specialist provider. The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs. j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for. k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission. l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation. m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective. 2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation. Discontinuity of Care/Management of Care 3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B. 4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units. 5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach. 6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager. 7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse. 8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway. 9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible. Risk Assessment/Care Planning 10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk. 11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required. ”

    Source location

    Linsay Bushell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. East London

    AI-generated summary

    Mrs Anna Teresa Walker · 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

    Mrs Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.

    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

    Chaotic transfer pathway for radiology patients to the ward

    Wider context from the report

    “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust. II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure). III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring. ”

    Source location

    Mrs Anna Teresa Walker · 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 of porters to collect post-procedure patients

    Wider context from the report

    “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust. II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure). III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring. ”

    Source location

    Mrs Anna Teresa Walker · 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 of ward nurses to receive post-procedure patients

    Wider context from the report

    “2. The Consultant Radiologist confirmed that in his opinion, the reasons for the failure to carry out the required observations were: I. The failure of the porters to collect the patient. He stated that the failure of the porters to attend, was reported as a serious incident. He stated that this issue has still not been resolved and is an ongoing issue within the Trust. II. The failure of nurses on the ward to take her back. (Albeit the evidence revealed that the nurses on the ward were concerned about her low blood pressure). III. The Consultant described a “chaotic situation” with patients coming in for treatment to the radiology department but patients not going up to the ward. IV. He stated that Mrs Walker was not in the appropriate environment for post-operative monitoring. ”

    Source location

    Mrs Anna Teresa Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Essex

    AI-generated summary

    Dean Gary Saunders · 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

    Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

    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 the admissions protocol to allow transfer of mentally disordered people from police custody

    Wider context from the report

    “1. FOR SEPT:- The admitted lacuna in the SEPT admissions protocol governing the transfer of mentally disordered people from police custody. The current admissions protocol does not allow for the transfer of any individual from police custody, irrespective of the criminal charges the individual is facing. ”

    Source location

    Dean Gary Saunders · 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

    Develop a local Transfer Policy setting out HMP Chelmsford’s processes under the Mental Health Pathway.

    Verbatim wording from the response

    “This revamped Mental Health Pathway is a strategic national policy and local sites develop local operating policies to describe how they will meet the requirements of the pathway. This will include a local Transfer Policy to outline the local processes (see below).”

    Source location

    2017-0056-Response-by-Care-UK
    Page 2 · response
    Published 5 March 2017

    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

    Submit the admissions protocol for regional review.

    Verbatim wording from the response

    “Although the admissions protocol used by the Trust is an all-inclusive one and does not exclude any scenario (provided that the individual has been detained under the Mental Health Act 1983) the Trust has submitted the protocol for regional review by the Secure Services Catchment Group for East of England and will ensure you are informed of the outcome.”

    Source location

    2017-0056-Response-by-Essex-Partnership-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    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 existing admissions protocol covers all scenarios involving individuals detained under the Mental Health Act 1983.

    Verbatim wording from the response

    “Although the admissions protocol used by the Trust is an all-inclusive one and does not exclude any scenario (provided that the individual has been detained under the Mental Health Act 1983) the Trust has submitted the protocol for regional review by the Secure Services Catchment Group for East of England and will ensure you are informed of the outcome.”

    Source location

    2017-0056-Response-by-Essex-Partnership-NHS-Trust
    Page 1 · response
    Published 5 March 2017

    Open published response
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Data last updated 7 September 2026