First reported 17 Sep 2013•Latest report 24 Jun 2026
Definition
What this concern includes
Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
Not included
Ordinary shift handover with no transfer of the patient or care responsibility
Clinical treatment failures after a safe and complete transfer
Discharge to the community where no healthcare transfer process is involved
Reports
103
Distinct published reports
Individual concerns
131
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
151
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England14
Department of Health and Social Care10
University Hospitals Sussex NHS Foundation Trust5
Betsi Cadwaladr University LHB4
HM Prison and Probation Service4
Manchester University NHS Foundation Trust4
Swansea Bay University Local Health Board4
University Hospitals of Derby and Burton NHS Foundation Trust4
Welsh Government4
Greater Manchester Mental Health NHS Foundation Trust3
Healthcare Inspectorate Wales3
Stockport NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust2
Bedfordshire Hospitals NHS Foundation Trust2
NHS trust66
Executive non-departmental public body15
Healthcare site13
Ministerial department11
Local health board10
Type not available7
Residential care home5
Devolved government4
Executive agency4
Health and care inspectorate3
Independent healthcare provider3
Prison or young offender institution3
Private limited company3
Company limited by guarantee2
Health and social care service regulator2
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
South Wales Central
Concerns raised1
Lack of comprehensive transfer handover of falls risk
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Portsmouth and South East Hampshire
Concerns raised1
Failure to implement consultants' requests for patient transfer to specialist wards
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.
Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.
Stated by Portsmouth Hospitals University NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Derby and Derbyshire
Concerns raised4
Failure to provide resuscitation equipment and drugs for medical emergencies during transfer
Failure to provide appropriate vital signs monitoring during transfer to and from the CT scanner
Failure to provide appropriately qualified clinical escort during transfer to and from the CT scanner
Failure to provide equipment and drugs to protect and manage the airway during transfer
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to provide proper handover during ward transfer
This report raised 17 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.
Birmingham and Solihull
Concerns raised1
Failure to highlight essential patient information during transfers between care homes
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement an additional action plan and timetable responding to the inquest findings.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Continue embedding all organisational policies and procedures at Aran Court.
Stated by Avery Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Raise the transfer and discharge communication lessons from the incident in a forthcoming quarterly Safety 1st bulletin shared across Amore Care Homes.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Highlight to home staff the requirement to complete Form AM32 Transfer Discharge records, including prompts for key information such as PCA behaviour.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Comprehensive pre-admission and transfer documentation is considered sufficient to identify relevant clinical risks when completed correctly.
Stated by Avery Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing admission and handover documents were considered sufficient to capture known risks during transfers when completed appropriately.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
System-wide direction on identifying essential transfer information is directed to the governing body, such as the regulator or relevant health department.
Stated by Priory GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The commissioning organisation should ensure receiving care homes can meet transferred patients’ needs; the Care Quality Commission may comment on this.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Failure to communicate absconding risk in written hospital transfer documentation
Failure to provide written confirmation of DOLS applications during hospital transfer
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2016.
Action
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Absence of a robust system for conveying summary medical information to receiving A&E departments during acute illness transfers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement a jointly authored procedure defining custodial and healthcare responsibilities for conveying summary medical information to receiving A&E departments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 June 2016.
Action
Undertake a compliance review of the information-transfer procedure to confirm full implementation of the system.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 June 2016.
Action
Share the information-transfer procedure at the Offender Health Learning the Lessons Forum to support adoption by other establishments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 June 2016.
West Yorkshire (Western)
Concerns raised1
Lack of criteria for doctor presence during ambulance transfer of critically ill patients
This report raised 10 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.
Mid Kent and Medway
Concerns raised1
Failure to inform the receiving ITU of patient transfers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
