Recurring concern

Unreliable coordination and outcome follow-up after tertiary-centre transfer

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First reported 30 Mar 2015•Latest report 2 Mar 2021

Definition

What this concern includes

Includes failures in the bounded tertiary-centre coordination and follow-up process, including communication about prior procedures, transfer-related clinical information, detection or review of adverse outcomes after transfer, and escalation or follow-up of resulting safety concerns.

Not included

Excludes generic inter-service communication or clinical-record failures where tertiary-centre coordination or post-transfer outcome follow-up is not the material concern.
Excludes failures in the underlying clinical treatment or outcome where no deficient tertiary-centre coordination or follow-up process is identified.
Excludes routine referral, transfer or specialist-access delays unrelated to coordinating information, adverse outcomes or follow-up after tertiary-centre involvement.
Excludes failures confined to a separately named condition-specific pathway when that pathway provides the more specific supported boundary.

Reports: 3
Individual concerns: 3
Date range: 2015–2021
Stated actions: 1

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.

Care Quality Commission1

Department of Health and Social Care1

East Kent Hospitals University NHS Foundation Trust1

East Lancashire Hospitals NHS Trust1

Health Services Safety Investigations Body1

Manchester University NHS Foundation Trust1

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.

2 Mar2021
Lancashire and Blackburn with Darwen
Concerns raised1
1. Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death
This report raised 16 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.
Respondent positions 2
1. Position
  Systematic follow-up of transferred patients who later die is difficult because the Trust depends on timely notification by other organisations.
  Stated by East Lancashire Hospitals NHS TrustUnable to act
1. Position
  The Regional Medical Examiner group is to consider establishing a cross-hospital feedback mechanism for detecting deaths after patient transfers.
  Stated by East Lancashire Hospitals NHS TrustRedirects responsibility
AI-generated summary

Mr Frank Charles Medley · 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 Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

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
Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death
Wider context from the report
“(1) The Trust has an ineffectual system to detect adverse outcomes where the patient is transferred to a tertiary centre for treatment and subsequently dies; ”
Source location
Mr Frank Charles Medley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Systematic follow-up of transferred patients who later die is difficult because the Trust depends on timely notification by other organisations.

Verbatim wording from the response
“You raised a concern re the lack of systems to follow up patients who once transferred go on to deteriorate in other Trusts. It has proved difficult to achieve this from a systems perspective. Achieving this is heavily reliant on the Trust being informed of a patient having unfortunately died, in a timely manner. Mr Medley’s case has clearly demonstrated the impact of the absence of this system, but no Trust we have spoken to has been able to describe a standardised systematic approach to”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 6 · response
Published 8 March 2021
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 Regional Medical Examiner group is to consider establishing a cross-hospital feedback mechanism for detecting deaths after patient transfers.

Verbatim wording from the response
“achieving this when asked. Recognising the focus and role of the Medical Examiners, across all Trusts; our Lead Medical Examiner has asked the Regional Team to consider whether these roles could support with this issue. We await a response.”

Source location
2021-0057-Response-from-Royal-Blackburn-Teaching-Hospital-Redacted
Page 7 · response
Published 8 March 2021
Open published response
18 Oct2018
Manchester South
Concerns raised1
1. Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joseph James GRANTHAM · 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

Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

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 defined protocol for transfer of paediatric care between tertiary centres and DGHs
Wider context from the report
“5. Joseph's health needs relating to neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation and laryngomalacia were dealt with by the RMCH. His paediatric care was transferred without discussion by St Mary's back to the DGH. The inquest was told that there is no set protocol/ procedure between tertiary centres and DGH's for this situation, which can lead to differing practices. ”
Source location
Joseph James GRANTHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Mar2015
Central and South East Kent
Concerns raised1
1. Failure to liaise with the tertiary centre about prior procedures
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.
Actions described in response 1
1. Action
  Publish and electronically disseminate a Risk Wise article reminding staff to reassess outstanding actions and consider contacting tertiary centres for guidance.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Contact with tertiary centres is not necessary for all patients returning to the Trust, but is appropriate after rare procedural complications.
  Stated by East Kent Hospitals University NHS Foundation TrustNo action considered necessary
AI-generated summary

Kelly Patrick WILLIS · 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

Kelly Patrick Willis underwent atrial ablation at St Thomas’ Hospital on 8 October 2012 and was subsequently admitted to William Harvey Hospital several times with symptoms of general unwellness. He died from cerebral infarction, multiple septic emboli and an atrio-oesophageal fistula complicating the ablation. The principal concerns were delays in contacting the tertiary centre and failure to act on an email advising that complications should be considered and investigated.

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 liaise with the tertiary centre about prior procedures
Wider context from the report
“Those caring for Mr Willis at William Harvey Hospital recognised the need to contact St Thomas’ Hospital about the procedure that he had undergone there but failed to liaise with the tertiary centre before 29th October, even though this was well documented in the medical records on the first and third admissions that it should be. I am of the opinion that contact with the tertiary centre which had operated on Mr Willis should have been made when he first presented at William Harvey Hospital on 14th October, and thereafter on 22nd October and on 25th October as Dr ████████ had requested. ”
Source location
Kelly Patrick WILLIS · 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
Publish and electronically disseminate a Risk Wise article reminding staff to reassess outstanding actions and consider contacting tertiary centres for guidance.

Verbatim wording from the response
“In order to bring your concerns to the attention of the clinical and nursing staff within the Trust an article will be included in the regular publication produced by the central Risk Management Team entitled Risk Wise. This publication is disseminated electronically to all members of Trust staff and is produced on a quarterly basis. The article will include reminders to all staff of the importance of ensuring that requested actions which are either documented within the healthcare records or advised of during handover sessions, and which appear to be outstanding at the time of review are reassessed with a view to subsequent completion. The article will also inform the reader of the importance of considering the need to make contact with tertiary treatment centres for further guidance and patient management, particularly where a patient has already received treatment from that centre.”

Source location
2015-0122-Response-by-East-Kent-Hospitals-University
Page 2 · response
Published 30 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
Contact with tertiary centres is not necessary for all patients returning to the Trust, but is appropriate after rare procedural complications.

Verbatim wording from the response
“appropriate or necessary for contact with tertiary centres to be made for all patients who subsequently return to our care, but it is appropriate in circumstances where patients suffer rare complications of procedures which they have undergone, such as in the case of Mr Willis. I fully understand that had timely contact been made with ████████ Mr Willis may have been offered further treatment for his condition and whilst the prognosis of long term survival would have been poor, he may have received alternative clinical care and management.”

Source location
2015-0122-Response-by-East-Kent-Hospitals-University
Page 2 · response
Published 30 March 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Ineffectual detection of adverse outcomes after tertiary-centre transfer and subsequent death

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs

Concerns raised1

Failure to liaise with the tertiary centre about prior procedures

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

Respondent positions 2

Actions described in response 1

Respondent positions 1