Recurring concern

Failure to ensure timely transfer to an appropriate hospital care environment

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First reported 23 Sep 2013•Latest report 24 Jun 2026

Definition

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.

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: 24
Individual concerns: 24
Date range: 2013–2026
Stated actions: 67

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 Care10

NHS England4

Greater Manchester Health and Social Care Partnership3

Betsi Cadwaladr University LHB2

Care Quality Commission2

University Hospitals Sussex NHS Foundation Trust2

Welsh Ambulance Services NHS Trust2

Aneurin Bevan University LHB1

Barking, Havering and Redbridge University Hospitals NHS Trust1

Chief Executive of National Institution for Health and Care Excellence1

Chief Executive of Royal College of Midwives1

Chief Executive of Royal College of Obstetricians and Gynaecologists1

Consultant orthopaedic surgeon1

Conwy County Borough Council1

Denbighshire County Council1

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.

23 Mar2015
Manchester South
Concerns raised1
1. Delays in transferring patients to the appropriate ward
This report raised 8 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 1
1. Action
  Review the Capacity and Flow Escalation Policy to define bed-allocation prioritisation based on clinical need.
  Stated by Stockport NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Orthopaedic wards need not provide cardiac monitoring because patients requiring it can be transferred to wards with appropriately trained staff.
  Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficient
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
5 Jun2014
Manchester South
Concerns raised1
1. Failure of timely coordination and availability for inter-hospital patient transfers
This report raised 7 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 2
1. Action
  Require liaison with Clinical Site Coordinators before arranging inter-site transfers to confirm bed availability.
  Stated by Manchester University NHS Foundation TrustStated planned
2. Action
  Continue embedding and refining the inter-site transfer process through ongoing review and small adjustments.
  Stated by Manchester University NHS Foundation TrustStated in progress
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
25 Feb2014
Brighton and Hove
Concerns raised1
1. Inappropriate transfer to an Acute Medical Unit
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.
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
23 Sep2013
Milton Keynes
Concerns raised1
1. Lack of beds delaying transfer to the Respiratory Team
This report raised 2 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

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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in transferring patients to the appropriate ward

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

Failure of timely coordination and availability for inter-hospital patient transfers

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

Concerns raised1

Inappropriate transfer to an Acute Medical Unit

Concerns raised1

Lack of beds delaying transfer to the Respiratory Team

Actions described in response 1

Respondent positions 1

Actions described in response 2