Recurring concern

Failure to ensure timely transfer to an appropriate hospital care environment

First to latest report 23 Sep 2013 — 24 Jun 2026

Reports that mention this concern
24
Times this concern has been raised
24
Stated actions linked to this concern
67

What this concern includes

Includes failures of the hospital transfer, bed-allocation or placement process that delay or prevent timely movement from an inappropriate setting to an available and clinically appropriate ward or alternative care environment.

What is not included
  • Excludes failures concerning only the quality or suitability of a care environment when no delayed or inappropriate transfer or placement process is identified.
  • Excludes generic staffing, resource or bed-capacity deficiencies unless they are directly tied to delayed or failed transfer or placement in an appropriate care environment.
  • Excludes unrelated admission, discharge, clinical-treatment or risk-assessment failures that do not concern transfer or placement in the appropriate hospital setting.

Reports and published responses 24 reports

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

  1. Manchester South

    AI-generated summary

    Pamela Pattison · 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

    Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.

    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 transferring patients to the appropriate ward

    Wider context from the report

    “7. There was a considerable delay of approximately 12 hours in moving her to ward A3 after she had been deemed the appropriate place for her to be. No reason for this delay was offered. ”

    Source location

    Pamela Pattison · 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

    Review the Capacity and Flow Escalation Policy to define bed-allocation prioritisation based on clinical need.

    Verbatim wording from the response

    “However the bed management team are aware that they need to balance priority of bed allocation based on clinical needs of all patients regardless of their location and any concerns could have been raised through the appropriate out of hours’ management structure. The Trust is in the process of reviewing its Capacity and Flow Escalation Policy which will reflect the bed allocation prioritisation process.”

    Source location

    2015-0108-Stockport-NHS-Trust
    Page 3 · response
    Published 23 March 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

    Orthopaedic wards need not provide cardiac monitoring because patients requiring it can be transferred to wards with appropriately trained staff.

    Verbatim wording from the response

    “b. Cardiac monitors/ward defibrillator Cardiac monitors are available on the diabetes speciality ward. It is accepted that there were none available for the orthopaedic ward; staff on these wards are not trained to interpret the output from a cardiac monitor so the most appropriate course of action would be to transfer those patients requiring cardiac monitoring to a ward where staff are trained to interpret and respond to the output from a cardiac monitor. In this instance the plan was to move Mrs Pattison as soon as possible; unfortunately this was not as timely as I would have hoped. This matter should then have been escalated through the appropriate out of hours’ management structure to ensure that her move was facilitated as soon as possible.”

    Source location

    2015-0108-Stockport-NHS-Trust
    Page 3 · response
    Published 23 March 2015

    Open published response

  2. Manchester South

    AI-generated summary

    THOMAS PATRICK MAHER · 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

    Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

    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 timely coordination and availability for inter-hospital patient transfers

    Wider context from the report

    “4. On or around the 3rd February, a discussion took place between the treating doctor at Trafford and an orthopaedic specialist at MRI, during which it was agreed that a bed was available at MRI and that Mr Maher would be transferred. The ambulance was ordered to transport him and Mr Maher was taken and placed in the vehicle. In fact it then transpired that there was no bed available so he had to be taken from the vehicle and returned to the ward at Trafford General. In the course of his evidence to me, the consultant Physician stated “we have major problems getting patients transferred to MRI and other hospitals, we frequently have to wait 3 or 4 days for transfer of a patient who should have gone immediately”. He then went on to state that in his opinion the ability to transfer patients between divisions of the same trust should be ‘second to none’ and in fact it is less than adequate. ”

    Source location

    THOMAS PATRICK MAHER · 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

    Require liaison with Clinical Site Coordinators before arranging inter-site transfers to confirm bed availability.

    Verbatim wording from the response

    “It has been agreed that in future all transfers between sites will not be arranged without liaison with the Clinical Site Coordinators to ensure that this unacceptable situation does not arise again.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 3 · response
    Published 5 June 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue embedding and refining the inter-site transfer process through ongoing review and small adjustments.

    Verbatim wording from the response

    “Trafford Division acknowledges that since implementation of the New Clinical Model in November 2013, there has been a period of significant change and time needed for the new transfer process to be embedded. A transfer policy has been in place since the New Clinical Model was established but adherence to this policy was variable in the early stages. Continuous efforts have been made to ensure that this is fully embedded in practice and we can offer assurance that since the start of this new system there have been 485 patient transfers between the two sites with no instances of patient harm reported as a result. Trafford Division is confident that staff are aware of the transfer policy and that this has been communicated to them. The Division is continually reviewing and making small adjustments to the transfer process in order to make improvements.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 3 · response
    Published 5 June 2014

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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

    Inappropriate transfer to an Acute Medical Unit

    Wider context from the report

    “(3) Inappropriate transfer to an Acute Medical Unit when he should either have stayed in A & E or gone to a Surgical Unit. The concern was that he was effectively unsafe and in an inappropriate clinical environment. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Milton Keynes

    AI-generated summary

    Sally King · 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

    Sally King was admitted to Milton Keynes Hospital after falling from her chairlift on 22 December 2012 and sustaining a fractured femur and ribs; the inquest concluded that she died as a result of an accident. Concerns included the failure of the Pain Team to see her during an admission of over three weeks and delays in transferring her to the Respiratory Team because of a lack of beds, with the transfer occurring on the day she died.

    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 beds delaying transfer to the Respiratory Team

    Wider context from the report

    “(2) ████████ a Consultant Orthopaedic Surgeon, in his evidence told me, “after three weeks of asking, the Respiratory Team eventually agreed to take over Mrs. King’s care. However her transfer was delayed due to lack of beds on ward 16.” Mrs. King was eventually transferred on the 6th February, the very day that she died. It would seem that she was not being cared for and treated on the appropriate ward or department. ”

    Source location

    Sally King · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026