Recurring concern

Inadequate coordination between hospitals during patient care

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First reported 13 Jan 2014•Latest report 24 Oct 2025

Definition

What this concern includes

Includes failures of the end-to-end coordination of patient care between hospitals, including engagement, transfer, treatment progression and ownership across specialist and non-specialist services.

Not included

Excludes coordination failures between organisations that are not hospitals or are unrelated to hospital-based patient care.
Excludes isolated communication, documentation or handover failures unless they demonstrate a broader failure of hospital-to-hospital care coordination.
Excludes generic staffing, resource or policy deficiencies that are not explicitly tied to coordination between hospitals.

Reports: 25
Individual concerns: 28
Date range: 2014–2025
Stated actions: 51

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.

NHS England7

Department of Health and Social Care5

Greater Manchester Health and Social Care Partnership2

Greater Manchester Mental Health NHS Foundation Trust2

Manchester University NHS Foundation Trust2

NHS Greater Manchester Integrated Care Board2

University Hospitals Sussex NHS Foundation Trust2

Blackpool Teaching Hospitals NHS Foundation Trust1

Bourne Leisure Limited1

Bristol NHS Foundation Trust1

Buckinghamshire Healthcare NHS Trust1

Central and North West London NHS Foundation Trust1

Derbyshire Community Health Services NHS Foundation Trust1

East Midlands Ambulance Service NHS Trust1

East of England Ambulance Service NHS 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.

5 Sep2022
West Sussex
Concerns raised1
1. Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT
This report raised 4 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
  Implement an inter-organisation transfer pathway that gives patients, GPs and receiving clinicians the receiving organisation’s nominated contact details.
  Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS TrustStated in progress
2. Action
  Ratify and use a proforma transfer letter, providing it to patients at their final face-to-face visit and copying it to their GP and receiving Clinical Nurse Specialist.
  Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS TrustStated in progress
AI-generated summary

Stephen WELLS · 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 Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.

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
Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT
Wider context from the report
“c) I heard evidence that Mr Wells was told his key contact in SASH was a named Clinical Nurse Specialist. When his care transferred to RSFT, witnesses expected his key contact to be changed to a CNS based within the St Luke’s Cancer Centre in Guildford. During the inquest I asked to whom the CNS was at RSFT and following enquiries learnt that the St Luke’s staff believed the key contact was the SASH CNS. I remain concerned that there is insufficient clarity for both patients and staff when there is an IPT from SASH to RSFT and vice versa. ”
Source location
Stephen WELLS · Prevention of Future Deaths report
Page 3 · 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 an inter-organisation transfer pathway that gives patients, GPs and receiving clinicians the receiving organisation’s nominated contact details.

Verbatim wording from the response
“Following the concerns identified during the inquest the Trusts have been working on an agreed pathway that will ensure that patients themselves receive a letter at the point when their care is due to be transferred to another organisation. This letter will contain the key contact details including a telephone number for the nominated point of contact at the receiving organisation. The patient will therefore always have the key contact details available to them. The letter will also be copied to the patients GP and to the receiving clinical nurse specialist at the receiving hospital. This ensures that the GP has access to the contact details of the nominated point of contact should they need to raise any concerns or otherwise make contact with the treating clinical team.”

Source location
Response from Royal Surrey Foundation Trust NHS
Page 3 · response
Published 4 October 2022
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
Ratify and use a proforma transfer letter, providing it to patients at their final face-to-face visit and copying it to their GP and receiving Clinical Nurse Specialist.

Verbatim wording from the response
“RSFT have developed a proforma letter to use at the point when a patient’s care is due to be transferred to another organisation. This letter is due to be ratified by the RSFT Oncology department on the 4th November and will then be used for all patients where care is being transferred from RSFT to our referring hospitals. Patients will receive this letter in person at their final face to face visit, this will avoid any issues with the letter being lost or delayed in a postal process and ensure that the patient is clear on how and who to contact should they have concerns following their transfer of care. The letter will then be copied to the patient’s GP and to the Clinical Nurse Specialist at the receiving Trust who will taking on the role of the nominated point of contact for that patient.”

Source location
Response from Royal Surrey Foundation Trust NHS
Page 4 · response
Published 4 October 2022
Open published response
16 Jun2022
West Sussex
Concerns raised1
1. Failure to communicate specialist referral priorities to local hospitals
This report raised 13 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

James Joseph MANNING · 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

James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

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 specialist referral priorities to local hospitals
Wider context from the report
“d) I also heard evidence to suggest that locally devised priorities agreed in specialist or tertiary centres (in this case the Royal Sussex County Hospital, Brighton) had not been communicated to local hospitals and shared so that doctors making a referral can consider the best place to refer a case taking into consideration relative waiting times. ”
Source location
James Joseph MANNING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
8 Jun2022
Birmingham and Solihull
Concerns raised1
1. Failure to make timely VITT specialist referral and transfer arrangements
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.
Actions described in response 1
1. Action
  Provide regulators with assurance about appropriate referral of future patients to tertiary services.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
AI-generated summary

Jack HURN · 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

Jack Hurn, aged 26, died after developing vaccine-induced immune thrombocytopenia and thrombosis with cerebral venous sinus thrombosis following an AstraZeneca COVID-19 vaccination. Concerns included the absence or non-use of guidance and pathways for timely specialist management of VITT, aspects of his care at Alexandra Hospital, and the apparent inadequacy of the investigation into his 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 make timely VITT specialist referral and transfer arrangements
Wider context from the report
“1. The Level Two Comprehensive Investigation of the Worcestershire Acute Hospitals NHS Trust ("WAH") concluded the root cause of Jack's death was: "There was no official national guidance and no approved Trust guidance on managing VITT in place at the time this patient was admitted to AGH, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB)." The following care and service delivery problems were identified: “There was no written Trust or national guidance on managing VITT at the time the patient was admitted, therefore staff are unlikely to have been aware of the time-critical need to transfer the patient to a specialist centre (QEHB).” The following Contributory factors were identified: - The Neurosurgical team at QEHB were contacted for advice; had the Trust VITT guidance been in place at the time, it would have stipulated not to contact the Neurosurgical team, but instead to contact Haematology and Neurology at QEHB. - The Neurosurgical team at QEHB advised to continue medical management locally (at WAHT). - Had the Trust VITT guidance been in place at the time, the WAHT Haematologist would have been prompted to contact their counterpart Haematologist at QEHB which may have accelerated the process of transfer; this did not happen until the day after the patient’s admission. 2. Within the course of the evidence at the inquest it was identified that, whilst there was no NICE Guidance or a local policy at WAH, there was a number of publications on the management of VITT and patients presenting with complications post Astra Zeneca Vaccination: i. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT) 28th May 2021 ii. Joint guidance from the Royal College of Emergency medicine, the Society for Acute Medicine and the Royal College of Physicians ‘Management of patients presenting to the Emergency Department/ Acute Medicine with symptoms 5-42 days post Astra Zeneca vaccine’ 24th May 2021 iii. 'Management of Cerebral Venous Sinus Thrombosis following COVID-19 vaccination. A neurosurgical guide.' from the British Society of Neurological Surgeons 19th April 2021 3. Evidence also identified that the University Hospitals Birmingham NHS Foundation Trust had also put in place a Regional VITT Pathway that was communicated to Haematologists and Neurologists across the region in March 2021. Prior to Jack's admission to the Alexandra Hospital on the 8ᵗʰ June 2021 4 patients had been transferred from the WAH to the QEH under the pathway including 1 patient from the Alexandra Hospital. 4. The WAH investigation did not identify the above guidance or Pathway and did not provide any explanation of why they were not followed in Jack's case. 5. Concerns were raised in the management of Jack's care whilst at the Alexandra Hospital, in particular the emergency department decision to refer to the medical and not neurology team, the level of observations whilst on ward 11 and the fact that family were reporting a concern that Jack was deteriorating during the afternoon of the 9ᵗʰ June 2021. The WAH investigation report does not record that these matters (or any other aspect of clinical care) were investigated, the conclusions reached or the basis for those conclusions. 6. This raises a concern that the investigation was not sufficient and as such has not served its purpose of safeguarding patients. 7. No adequate explanation was given in evidence to explain why the investigation was incomplete. 8. If WAH serious incident investigations are not sufficient the lessons arising will not be identified and necessary action will not be taken putting lives at risk. ”
Source location
Jack HURN · 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
Provide regulators with assurance about appropriate referral of future patients to tertiary services.

Verbatim wording from the response
“I confirm that we have discussed the concerns raised with the Care Quality Commission and Clinical Commissioning Group (as was), in particular providing assurance about the actions taken in order that any future patients presenting at our sites are referred appropriately to tertiary services.”

Source location
Response from NHS Worcestershire Acute Hospital
Page 2 · response
Published 16 September 2022
Open published response
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. Failure to formalise urgent ophthalmic patient transfer arrangements
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 1
1. Action
  Develop and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  A formal urgent-transfer agreement may not prevent similar incidents, so the concern is addressed through responsive protocols within existing services.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Douglas OWENS · 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 Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 formalise urgent ophthalmic patient transfer arrangements
Wider context from the report
“(1) That Blackpool Victoria Hospital has not yet finalised an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital when appropriate. Unless arrangements are formalised, the lives of patients may be put at risk. ”
Source location
Douglas OWENS · 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 and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.

Verbatim wording from the response
“The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 1 · response
Published 3 December 2020
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
A formal urgent-transfer agreement may not prevent similar incidents, so the concern is addressed through responsive protocols within existing services.

Verbatim wording from the response
“The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 1 · response
Published 3 December 2020
Open published response
30 Dec2019
Manchester South
Concerns raised1
1. Failure to share anticoagulant reversal risks with non-tertiary centres
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

Maureen Waterfall · 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

Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.

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 share anticoagulant reversal risks with non-tertiary centres
Wider context from the report
“2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients. The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations. ”
Source location
Maureen Waterfall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Dec2019
Manchester South
Concerns raised1
1. Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres
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

Joyce Marchant · 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

Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.

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 communication strategy and treatment plan between DGHs and tertiary centres
Wider context from the report
“3. The MRI was the treating centre for Mrs Marchant’s underlying medical problems which led to her deterioration. However there was no evidence of a clear communication strategy or treatment plan involving the DGH and Tertiary Centre. This was attributed in part to the sheer volume of demand on tertiary centres and the extent of support they can provide to DGHs. ”
Source location
Joyce Marchant · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jun2019
Manchester North
Concerns raised1
1. Lack of specialist knowledge to recognise the association between Cushing’s disease and PJP
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.
Actions described in response 4
1. Action
  Issue a group-wide patient care alert highlighting the risk of pneumocystis pneumonia in patients with Cushing’s disease.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
2. Action
  Disseminate investigation learning through medical, intensive care, and clinical governance meetings, including guidance on assessing and treating pneumocystis pneumonia risk.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
3. Action
  Include Cushing’s disease awareness in annual Core Medical Trainee training and ensure trainees understand atypical infection risks.
  Stated by Northern Care Alliance NHS Foundation TrustStated completed
1. Action
  Consider using this case as a specific case study for future learning.
  Stated by Northern Care Alliance NHS Foundation TrustStated planned
AI-generated summary

Deborah Anne Hopkinson · 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

Deborah Anne Hopkinson was treated for Cushing’s disease caused by a pituitary adenoma and later developed pneumocystis pneumonia. Her condition deteriorated during intensive care, and she died at Fairfield General Hospital on 26 September 2018 after a cardiac arrest. Concerns included equipment failures, delays in specialist advice and delays in recognising and treating complications associated with Cushing’s disease.

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 specialist knowledge to recognise the association between Cushing’s disease and PJP
Wider context from the report
“2. There was delay in obtaining advice from a specialist centre such as Salford Royal Hospital or the Christie Hospital despite a lack of expertise at Fairfield General Hospital as evidenced by the following: i. ████████ Consultant Endocrinologist at Salford Royal Hospital explained to the deceased’s husband ████████ and her sister ████████ that she was not a specialist in Cushing’s disease when discussing the deceased’s case on 17 September 2018. ii. In the Investigation Report the Trust accepted that there had been a delay in treatment for probable PJP because the medical team did not recognise the association between Cushing’s disease and PJP due to lack of specialist knowledge. On 21 August 2018 an MRI pituitary revealed a pituitary adenoma which was the most likely cause of the deceased’s Cushing disease yet it was not until 28 August 2018 that ████████ Consultant Endocrinologist at Salford Royal Hospital was contacted. Prior to the deceased’s re-admission to hospital on 12 September 2018 she contracted pneumocystis pneumonia, a recognised complication of Cushing’s disease. There was delay in obtaining advice from a specialist centre despite a significant deterioration in her condition and when there was involvement from a Consultant Endocrinologist at the Christie Hospital this was only achieved because of the intervention of the deceased’s sister. ”
Source location
Deborah Anne Hopkinson · 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
Issue a group-wide patient care alert highlighting the risk of pneumocystis pneumonia in patients with Cushing’s disease.

Verbatim wording from the response
“It is accepted that there was a delay in ████████ becoming involved and seeking further advice from specialists when Mrs Hopkinson was re-admitted on 12 September 2018, due to the IT system downtime as addressed above and the Trust wishes to sincerely apologise to Mrs Hopkinson’s family for this.”

Source location
2019-0133-Response-by-Northern-Care-Alliance-NHS-Trust
Page 3 · response
Published 14 June 2019
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
Disseminate investigation learning through medical, intensive care, and clinical governance meetings, including guidance on assessing and treating pneumocystis pneumonia risk.

Verbatim wording from the response
“To further disseminate the learning from this investigation this case was discussed in Morbidity & Mortality meetings held by both the medical and ICU teams. In addition, the case was discussed in detail at a Clinical Governance meeting on 19 March 2019, when the patient safety alert and learning from the RCA was covered again.”

Source location
2019-0133-Response-by-Northern-Care-Alliance-NHS-Trust
Page 3 · response
Published 14 June 2019
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
Include Cushing’s disease awareness in annual Core Medical Trainee training and ensure trainees understand atypical infection risks.

Verbatim wording from the response
“Awareness of Cushing’s Disease is also included in the annual training for Core Medical Trainees. Dr Smithurst will ensure that the consultant delivering this training is aware of this case and ensure that all trainees are aware that due to the immunosuppression that occurs in Cushing’s disease and Cushing’s syndrome, patients are at risk of atypical infections, including pneumocystis pneumonia.”

Source location
2019-0133-Response-by-Northern-Care-Alliance-NHS-Trust
Page 3 · response
Published 14 June 2019
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
Consider using this case as a specific case study for future learning.

Verbatim wording from the response
“Trainees will also be reminded of the need to refer to the endocrine team urgently if they suspect Cushing’s, or if they are dealing with a patient already diagnosed with the condition. Consideration will be given to using this case as a specific case study to further future learning.”

Source location
2019-0133-Response-by-Northern-Care-Alliance-NHS-Trust
Page 4 · response
Published 14 June 2019
Open published response
24 Dec2018
Buckinghamshire
Concerns raised1
1. Lack of a clear, formalised understanding for obtaining nearest-hospital assistance to stabilise compromised airways
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

Joyce Phoebe Mary LONG · 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

Joyce Phoebe Mary LONG died in hospital at 0034 hours on 11 July 2018 after striking her head at home the previous day and later collapsing. The report raised concern about differing interpretations of the reception policy at Wycombe Hospital, creating a risk that assistance to stabilise a patient's airway could be refused or delayed in similar circumstances.

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, formalised understanding for obtaining nearest-hospital assistance to stabilise compromised airways
Wider context from the report
“(1) Shortly after Mrs Long had been mobilised into an ambulance outside her home address in Hazlemere, near High Wycombe, Buckinghamshire, her condition deteriorated very quickly and her Glasgow Coma Score dropped from 15/15 to 3/15. Her breathing became abnormal and irregular and she became unresponsive. Although the overall intention was to transport to John Radcliffe Hospital as a result of the traumatic head injury, the ambulance crew contacted and requested assistance from the nearest hospital, Wycombe Hospital, due to the concern over Mrs Long’s compromised airway. Admission was refused with an instruction to attend the nearest Accident & Emergency Unit so, instead, roadside assistance was provided to the crew near Stokenchurch at the M40 junction from an Enhanced Care Response Unit whilst en route to John Radcliffe Hospital. Due to the severity of the injury Mrs Long had sustained, exacerbated over the day prior to collapse by her warfarin prescription, the refusal of assistance by Wycombe Hospital (part of Buckinghamshire Healthcare NHS Trust) did not impact upon the outcome in this case. There was, however, a clear difference of opinion between South Central Ambulance Service and Buckinghamshire Healthcare NHS Trust as to the interpretation of the reception policy appropriate to the Cardiac and Stroke Unit at Wycombe. It is understood that informal discussions have been had between both trusts about whether South Central Ambulance Service should or should not be seeking assistance from Wycombe Hospital (where it is the nearest facility) in cases where a compromised airway may lead to cardiac arrest. There is a continuing concern that, in the absence of a clear, formalised understanding, circumstances may arise where either help to stabilise a patient’s airway is refused, or a delay occurs as a result of confusion, and a patient dies as a consequence. ”
Source location
Joyce Phoebe Mary LONG · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Jul2018
Brighton and Hove
Concerns raised1
1. Failure to arrange early transfer to an appropriate specialist hospital
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

Rita Elizabeth GILES · 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

Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.

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 arrange early transfer to an appropriate specialist hospital
Wider context from the report
“(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork. (2) The Trust’s own Transfer Policy not adhered too in any respect. (3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later. (4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement. There was a failure to appreciate that as she was already septic when she came in the matter was urgent. From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round. ”
Source location
Rita Elizabeth GILES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Nov2017
Gloucestershire
Concerns raised1
1. Failure to appropriately expedite urgent emergency transfers between hospitals
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

Susan Ann Smalley · 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

Susan Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.

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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 appropriately expedite urgent emergency transfers between hospitals
Wider context from the report
“3. When urgent emergency transfers are requested between hospitals, how they are appropriately expedited. ”
Source location
Susan Ann Smalley · 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

Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT

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

Failure to communicate specialist referral priorities to local hospitals

Concerns raised1

Failure to make timely VITT specialist referral and transfer arrangements

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

Concerns raised1

Failure to formalise urgent ophthalmic patient transfer arrangements

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 to share anticoagulant reversal risks with non-tertiary centres

Concerns raised1

Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres

Concerns raised1

Lack of specialist knowledge to recognise the association between Cushing’s disease and PJP

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.4

Concerns raised1

Lack of a clear, formalised understanding for obtaining nearest-hospital assistance to stabilise compromised airways

Concerns raised1

Failure to arrange early transfer to an appropriate specialist hospital

Concerns raised1

Failure to appropriately expedite urgent emergency transfers between hospitals

Actions described in response 2

Actions described in response 1

Actions described in response 1

Respondent positions 1

Actions described in response 4