Recurring concern

Inadequate specialist placement arrangements for people requiring specialist care

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First reported 27 Oct 2014•Latest report 7 May 2026

Definition

What this concern includes

Includes deficiencies in identifying, assessing, accessing or securing suitable specialist placements when the placement is intended to meet materially specialised care or risk-management needs.

Not included

Excludes generic shortages of accommodation or beds that are not tied to specialist care needs.
Excludes ordinary discharge, transfer or residential placement failures where no specialist placement requirement is identified.
Excludes failures in unrelated assessment, communication or organisational processes that are not dedicated to specialist placement arrangements.

Reports: 23
Individual concerns: 32
Date range: 2014–2026
Stated actions: 46

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care13

NHS England10

Department for Education2

HM Prison and Probation Service2

Cardiff Prison1

Cardiff & Vale University LHB1

Cheshire and Wirral Partnership NHS Foundation Trust1

East Kent Hospitals University NHS Foundation Trust1

Essex County Council1

Essex Partnership University NHS Foundation Trust1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Health and Safety Executive1

HM Prison Service1

Ministry of Justice1

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.

16 Nov2016
Portsmouth and South East Hampshire
Concerns raised1
1. 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 1
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 completed
Respondent positions 1
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 concern
AI-generated summary

Christopher Allen MacMORLAND · 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

Christopher Allen MacMORLAND was admitted to hospital with feeding difficulties and later readmitted with abdominal pain and distension; his condition deteriorated and he died on 5 December 2015. The substantive concern was that, despite five requests by consultant gastroenterologists, he was not transferred to a specialist gastroenterology ward, and evidence indicated that such a ward might have affected the outcome.

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 implement consultants' requests for patient transfer to specialist wards
Wider context from the report
“I was told in evidence at the Inquest that despite Mr MacMORLAND being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward - even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence I heard, I am of the opinion that he could have benefited from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome. I was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented. ”
Source location
Christopher Allen MacMORLAND · 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
Implement a buddy ward system to cohort specialty patients in their appropriate specialist or designated buddy ward.

Verbatim wording from the response
“By way of further assurance, since this death in 2015, the Hospital has begun a ‘buddy’ ward system whereby patients of a certain specialty are cohorted only into the appropriate specialist ward or a specific buddy ward. This means that consultants will have their patients only on one other ward if their own base ward is full.”

Source location
2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 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
Care was not compromised because the surgical ward staff were familiar with medical gastrointestinal disorders.

Verbatim wording from the response
“The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon. The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised.”

Source location
2016-0415-Response-by-Portsmouth-Hospitals-NHS-Trust
Page 1 · response
Published 19 February 2017
Open published response
6 Jul2015
South Yorkshire (Eastern)
Concerns raised1
1. Lack of suitable alternative residential placement for residents with high nursing needs
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.
AI-generated summary

Phyllis Broomhead · 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

Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

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 suitable alternative residential placement for residents with high nursing needs
Wider context from the report
“(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home. ”
Source location
Phyllis Broomhead · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Oct2014
Central and South East Kent
Concerns raised1
1. Failure to secure an appropriate High Dependency Unit bed for a high-risk postoperative patient
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.
AI-generated summary

Betty SMITH · 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

Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising 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 secure an appropriate High Dependency Unit bed for a high-risk postoperative patient
Wider context from the report
“• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management. ”
Source location
Betty SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to implement consultants' requests for patient transfer to specialist wards

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

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

Concerns raised1

Lack of suitable alternative residential placement for residents with high nursing needs

Concerns raised1

Failure to secure an appropriate High Dependency Unit bed for a high-risk postoperative patient

Actions described in response 1

Respondent positions 1