Recurring concern

Unreliable healthcare patient transfer processes

First to latest report 17 Sep 2013 — 24 Jun 2026

Reports that mention this concern
103
Times this concern has been raised
131
Stated actions linked to this concern
151

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.

What is 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 and published responses 103 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Nottinghamshire

    AI-generated summary

    Douglas Kay · 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

    Douglas Kay, an elderly man aged 90, died approximately seven hours after becoming suddenly unwell with a catastrophic bleed from a duodenal ulcer on 22 November 2014. Outstanding concerns included confusion about transferring patients with gastrointestinal bleeding and a lack of awareness among key Bassetlaw Hospital staff about the arrangements for the Doncaster gastrointestinal bleeding service, particularly out of hours.

    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 agreed policy or procedure for transferring patients with gastrointestinal bleeding

    Wider context from the report

    “There remain significant confusion, and uncertainty about how, and when, to transfer a patient with gastrointestinal bleeding, with no clear agreed policy or procedure available within the Trust ”

    Source location

    Douglas Kay · 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

    Develop an Upper GI Bleed Transfer Policy for Bassetlaw Hospital patients requiring transfer to Doncaster.

    Verbatim wording from the response

    “which is particularly relevant in this case is the Upper GI Bleed Transfer Policy at Bassetlaw Hospital for those patients who require to be referred to Doncaster for further management of their upper GI bleeding. This policy has been developed after consultation between the anaesthetic and the medical teams.”

    Source location

    DBH-Trust-Response
    Page 2 · response
    Published 5 February 2016

    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

    Make Bassetlaw staff aware of the specific Upper GI Bleed Transfer Policy through the Clinical Site Manager and Matron.

    Verbatim wording from the response

    “All staff will be made aware of this specific transfer policy at Bassetlaw through the Clinical Site Manager and Matron at Bassetlaw.”

    Source location

    DBH-Trust-Response
    Page 2 · response
    Published 5 February 2016

    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 Upper GI Bleed Transfer Policy for ratification by the Patient Safety Review Group to support wider Trust dissemination.

    Verbatim wording from the response

    “The policy will also be ratified at the next meeting of the Patient Safety Review Group and this will ensure wider dissemination throughout the Trust.”

    Source location

    DBH-Trust-Response
    Page 2 · response
    Published 5 February 2016

    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

    Monitor implementation of the Upper GI Bleed Transfer Policy through the Emergency Care Group Clinical Governance Team and Datix incident system.

    Verbatim wording from the response

    “I trust that this will provide the assurance you require that appropriate action has been taken following the death of Douglas Kay. The implementation will continue to be monitored by the Emergency Care Group Clinical Governance Team through the Datix incident system.”

    Source location

    DBH-Trust-Response
    Page 2 · response
    Published 5 February 2016

    Open published response

  2. Central and South East Kent

    AI-generated summary

    Kevin John Gilbert · 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

    Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.

    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

    Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery

    Wider context from the report

    “• Given that Mr Gilbert was presenting at William Harvey Hospital as an acute emergency requiring specialist surgery at a tertiary centre and that his diagnosis of suspicion made on presenting clinical symptoms by a Consultant in Accident and Emergency medicine which was confirmed by CT scan, it was not reasonable for ████████ to rely on his understanding of the procedure of accepting such patients and wait for the CT imagery before agreeing that he could be transferred. ”

    Source location

    Kevin John Gilbert · 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

    Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.

    Verbatim wording from the response

    “In January 2015, shortly after Mr Gilbert died, the referring consultant wrote to Mr Avlonitis, consultant cardiothoracic surgeon and raised concerns about the delay in transfer. Following receipt of the letter Mr Avlonitis wrote to all registrars in the Cardiothoracic Department to clarify the department’s process for accepting dissection referrals. He confirmed that all such referrals must be discussed immediately with the duty consultant and any decision to ask to review CT imagery before transfer could only be made by a consultant. The text of the email is shown below.”

    Source location

    Kevin-GILBERT-Response
    Page 2 · response
    Published 14 December 2015

    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

    Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.

    Verbatim wording from the response

    “I would also like to make the Coroner aware of a more recent change to the management of dissection referrals at the Trust. It has always been the case that there is an ‘open door’ policy for leaking abdominal aortic aneurysms, meaning they are accepted by the vascular surgical team for immediate transfer if clinically appropriate, with a guarantee that theatre and critical care capacity will be made available. This approach has now been extended to include dissections of the ascending aorta and arch such as suffered by Mr Gilbert. Therefore, from May 2016, any such referral to this Trust will be discussed immediately with the duty consultant cardiac surgeon (as outlined above), who will then be able to authorise immediate transfer if clinically indicated, with that same guarantee that theatre and critical care capacity will be made available.”

    Source location

    Kevin-GILBERT-Response
    Page 2 · response
    Published 14 December 2015

    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

    Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.

    Verbatim wording from the response

    “The Trust is absolutely committed to learning from incidents and about how care can be improved and delivered more effectively. I am confident that following the email, and the reinforcement of the message by consultant staff, that all junior staff are completely clear that dissection referrals must be reviewed immediately by the duty consultant and they understand that the transfer decision must be made by a consultant.”

    Source location

    Kevin-GILBERT-Response
    Page 2 · response
    Published 14 December 2015

    Open published response

  3. Worcestershire

    AI-generated summary

    Bryan Arnold CATANACH · 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

    Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.

    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 communication during inter-hospital transfers

    Wider context from the report

    “(1) There were a number of difficulties with communication between the various clinicians and hospital Trusts. This led to a delay in the initial transfer of the patient, a delay in his subsequent review by a senior clinician and confusion on the part of nursing staff as to whether Mr Catanach was to be kept nil by mouth and/or given his prescribed medication. While it is a matter for you it may be that the Trust will want to reflect on whether there is a need to standardize its inter-hospital transfer process so that nursing as well as medical staff are fully engaged with the process. ”

    Source location

    Bryan Arnold CATANACH · 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

    Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.

    Verbatim wording from the response

    “Difficulties with communication between various clinicians and hospital Trusts. The Trust has looked to progress improved communication routes and systems in preparedness for the receipt of an emergency/unscheduled patient. As was explained within your Court, ROH acts as a regional centre for a range of spinal emergencies. Broadly speaking two to three spinal emergencies are transferred into the ROH each week for emergency elective care. Following this court hearing, the Trust has refreshed and reaffirmed its receiving and first line management processes in preparedness for the arrival of such patients. The Trust robustly pursues the ring fencing of a single spinal emergency bed and this provides a guaranteed safe point of arrival for any inbound emergency patient.”

    Source location

    Bryan-Catanach-Response
    Page 1 · response
    Published 1 December 2015

    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

    Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.

    Verbatim wording from the response

    “Additional concerns over communications Following apparent communication and messaging issues identified in this case, Mr Newton-Ede has led a piece of work to refresh and simplify proforma based documentation. Both nursing and medical members of the multi-disciplinary team have been involved in delivering this change. There is a clearly held view from clinical colleagues that these developments have already been seen to be positively impacting on improved communication flow and necessary escalation.”

    Source location

    Bryan-Catanach-Response
    Page 2 · response
    Published 1 December 2015

    Open published response

  4. South Yorkshire (Eastern)

    AI-generated summary

    Dorothy Cooper · 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

    Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.

    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 identify and transfer key clinical information to receiving teams

    Wider context from the report

    “During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this. My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture. Matters of concern in summary are : 1. Inadequate training of junior doctors who complete referral forms. 2. A lack of understanding as to what key information is required in referrals of this nature. 3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team. ”

    Source location

    Dorothy Cooper · 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

    Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.

    Verbatim wording from the response

    “The process of inter-provider transfer of care for patients on cancer pathways in West Yorkshire is being revised, collaboratively at present. Both The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are centrally involved in that improvement work. The main action to improve handover of cases like Mrs Cooper’s will be to embed the revised processes detailed in the Standard Operating Procedure being drafted subsequent to that review. We expect this will be embedded by the end of February 2016.”

    Source location

    2015-0412-Response
    Page 1 · response
    Published 21 October 2015

    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

    Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.

    Verbatim wording from the response

    “2. The electronic transfer of imaging and other clinical data to support specialist opinions is well embedded, and appears to have functioned adequately in this case. Further promotion of the systems and processes by which this can be achieved will be distributed through our local Mid Yorkshire MDT’s. (completion by end of January 2016)”

    Source location

    2015-0412-Response
    Page 3 · response
    Published 21 October 2015

    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

    Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.

    Verbatim wording from the response

    “To reiterate the importance of submitting relevant clinical information, the Hepatobiliary MDT Co-ordinator has re-circulated the pathway document that was updated in October 2014 and highlighted the need for completion of the referral form as fully and accurately as possible.”

    Source location

    2015-0412-Response2
    Page 3 · response
    Published 21 October 2015

    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 lack of clinical details did not influence the final diagnosis, treatment or outcome.

    Verbatim wording from the response

    “The MDT has noted that you have raised concerns that they reviewed Mrs Cooper’s case at their MDT meeting without adequate clinical details. They wish to highlight the fact that they did make attempts to obtain the details by way of correspondence with Mid-Yorkshire NHS Trust (Pinderfields General Hospital). The team is clear however that the lack of details did not influence the final diagnosis, treatment or outcome.”

    Source location

    2015-0412-Response2
    Page 2 · response
    Published 21 October 2015

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Andrew Selwyn Roberts · 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

    Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.

    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 the Transfer of Care Form to escorting police for immediate availability to the custody nurse

    Wider context from the report

    “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse. ”

    Source location

    Andrew Selwyn Roberts · 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 completion of the Transfer of Care Form by the examining doctor

    Wider context from the report

    “1. That the Transfer of Care Form was not completed by the Doctor who had carried out the examination of the patient and the information contained therein was subsequently found to be inaccurate. ”

    Source location

    Andrew Selwyn Roberts · 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 in completing the Transfer of Care Form at the time of examination

    Wider context from the report

    “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse. ”

    Source location

    Andrew Selwyn Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Brian Anthony Gillard · 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

    Brian Anthony Gillard, who had asbestosis and required ambulatory oxygen, died at Royal Bolton Hospital on 20 March 2015 after collapsing and suffering a cardiac arrest while using the toilet. The concerns included a lack of handover about his oxygen requirement, transfer to the toilet without oxygen, and leaving him unsupervised in a toilet without an emergency pull-cord.

    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 hand over patients’ continuing oxygen requirements during transfers between hospital departments

    Wider context from the report

    “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia. iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward. ”

    Source location

    Brian Anthony Gillard · Prevention of Future Deaths report
    Page 3 · 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 required oxygen during patient transfers within a ward

    Wider context from the report

    “iii. There was no handover in relation to Mr Gillard’s transfer from the Emergency Department at the Hospital to D1 Ward at the Hospital, particularly in relation to his need for Ambulatory Oxygen and subsequently he was taken to the toilet without the use of Oxygen. He was left in the toilet on his own, and without supervision by a Nurse outside the door, for approximately four minutes during which he suffered a cardiac arrest believed to be secondary to Hypoxia. iv. It was accepted that there was a facility to use a portable Oxygen supply for use between his bed and the toilet but the portable supply was not used because Mr Gillard was happy to go to the toilet without Oxygen and his need for Ambulatory Oxygen was not known to the Ward Staff on D1 Ward. ”

    Source location

    Brian Anthony Gillard · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. Brighton and Hove

    AI-generated summary

    MR. ANTHONY GEERTS · 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. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.

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    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 follow and document ward transfer procedures

    Wider context from the report

    “Mr. GEERTS went to Princess Royal Hospital to Twineham Ward (the Ward which specialise in Rehabilitation patients coming from The Royal Sussex County Hospital in Brighton). Mr. GEERTS came with a fractured neck of femur which had been timeously operated. He was determined to return home to his wife who depended on him. He lived in Brighton and Hove and was disappointed to be going to Haywards Heath for rehabilitation as he knew how difficult it would be for his family to visit so regularly. In Brighton he had received physiotherapy and been regularly reviewed. In Haywards Heath he was effectively abandoned from the 6th. His notes give no clue as to how he was cared for. His physiotherapy notes end abruptly with no plan. I was told nurses on this rehabilitation ward had been asked to look after him as (a) There was insufficient physiotherapy staff to do so and (b) Without any or any effective consultation, the decision had been made that he was to be discharged to highgrove Nursing Home as soon as possible after the 6th. Neither Mr. GEERTS nor his family were involved in this decision. Mr. GEERTS had suffered long term mental health issues. These were ignored during his stay at Princess Royal Hospital. His anxieties were not addressed in any meaningful way. He was given no assistance after the 6th. Having been told he was to be transferred for further rehabilitation, Mr. GEERTS remained very anxious about the impending move and about the lack of communication and particularly the lack of physio. For reasons unexplained satisfactorily to this day, he was moved out of Twineham Ward late on the 10th, Bailey Ward was unaware of his needs. He was incontinent of urine. On the 11th he was transferred to the discharge ward from where he contacted his daughter 3 times. He arrived in a poorly state at Highgrove in the mid afternoon. This resulted in him being unable to participate fully in any of the Highgrove activities, nor could he settle in. He was back at The Royal Sussex County Hospital on the 16th with Hospital Acquired Pneumonia and ? urinary tract infection. No more physiotherapy was possible and in spite of ongoing treatment he deteriorated to his death on the 21st. Specifically at Princess Royal Hospital: • Notes not completed. • No nursing notes and no NEWS for 10th or 11th • Fluid chart not completed. Fluid restriction not properly documented. Fluid restriction effectively disregarded. • No plan for physiotherapy • No rehabilitation on Rehabilitation Ward from 6th -10th. Exercise on the 10th not properly documented. • No proper notes of Rationale for transfer to Bailey Ward on 10th/11th. Transfer procedure not followed. Transfer not documented. • No referral of lack of urinary continence. Therefore no plan regarding this. • Failed Trial without catheter on 3rd November 2014. • Bowel monitoring chart not complete • Discharge planning non-existent or inadequate • Communication with patient and family virtually non-existent • No senior review from 4th November 2014; possibility of chest infection not followed up. • Should have had a blood test as requested on 11th November 2014. Did not and therefore unnecessary extra 48 hours on fluid restriction. • Discharge lounge information incorrect. ”

    Source location

    MR. ANTHONY GEERTS · 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

    Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.

    Verbatim wording from the response

    “g) educational sessions with ward nurses to explore the rationale for moving patients. This will include both emphasis on the need to provide adequate information to the clinical site manager if consideration is being given to moving a patient (especially late at night), and teaching on the documentation requirements (including completion of the transfer document), should it be unavoidable for a patient to be moved from one ward to another. This will help ensure that adequate information accompanies any patient who, for whatever reason, has to be moved from one ward to another.”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    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

    Discuss avoiding late-night patient moves with clinical site managers responsible for bed allocation.

    Verbatim wording from the response

    “In addition, there have been discussions with the clinical site managers, who are the senior nurses on duty 24 hours a day on each site, with responsibility for allocating beds for patients. These staff are well aware that it is undesirable to move any patient late at night, even though this may be unavoidable in order to accommodate patients admitted through the Emergency Department.”

    Source location

    2015-0240-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    Open published response

  8. Wiltshire and Swindon

    AI-generated summary

    Elizabeth Godwin · 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

    Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.

    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 communicate and acknowledge transfers of patient care between agencies

    Wider context from the report

    “I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”

    Source location

    Elizabeth Godwin · 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

    Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.

    Verbatim wording from the response

    “Any other transfer of care should be documented in the same way as a clear statement of who is doing what - across the different teams in Wiltshire Council and AWP and across daytime hours and out of hours – which has been agreed by both organisations and needs to be clearly communicated to the families and the GP and anyone else who needs to be informed. This should be clearly recorded on the health data base RiO and the social care system CareFirst and via any other correspondence that is required.”

    Source location

    2015-0233-Response-by-Wiltshire-Council
    Page 5 · response
    Published 19 June 2015

    Open published response

  9. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 use the required trolley for patient transfer

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Howell Glyndwr Fisher · 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

    Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within 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

    Lack of transfer handover information about high falls risk

    Wider context from the report

    “(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls. ”

    Source location

    Howell Glyndwr Fisher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026