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

Distinct published reports

Individual concerns
28

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
51

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

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.

  1. Bedfordshire and Luton

    AI-generated summary

    Isla Peyton LORD · 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

    Isla Peyton LORD was born at Harlow Hospital on 4 November 2012 and suffered an immediate post-natal collapse after delivery, resulting in a hypoxic brain injury. She was transferred to Luton and Dunstable Hospital, where treatment was withdrawn following discussions with her parents, and she died on 8 November 2012. The principal concern was the lack of liaison between the hospitals about the delivery plan after possible heart anomalies were identified.

    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 coordinate an agreed delivery plan between tertiary and local hospitals

    Wider context from the report

    “1. During the course of the evidence it became apparent that once the possibility of heart anomalies was identified at University College Hospital in London (UCLH), there was no liaison between Princess Alexandra Hospital in Harlow and UCLH as to the plan for the delivery of the baby. It was simply agreed that UCLH were content for her to be delivered at the local hospital with a referral being made to Great Ormond Street Hospital after delivery. In order to prevent deaths in the future there needs to be a review of the system that exists between the tertiary hospitals and Princess Alexandra Hospital as to how to formulate an Agreed Delivery Plan for both mother and baby. ”

    Source location

    Isla Peyton LORD · 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

    Amend the obstetric ultrasound policy to require consultants to obtain and clearly document agreed delivery and neonatal care plans.

    Verbatim wording from the response

    “1. The Standard Operating Policy for obstetric ultrasound scanning has been amended to include that consultants in charge of patients referred for second opinion in tertiary centres should request a detailed plan for delivery of the mother and care of the baby. The policy also requests the consultants to document the plan clearly in the patient’s hand held notes and hospital notes.”

    Source location

    I-lord-Response
    Page 1 · response
    Published 5 February 2016

    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 the amended policy by adding it to the Trust guidelines folder and notifying obstetric doctors.

    Verbatim wording from the response

    “2. The new policy has been added to the Trust guidelines folder accessible by all clinicians.”

    Source location

    I-lord-Response
    Page 1 · response
    Published 5 February 2016

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Emmanuel Tobiloba Akinmuyiwa · 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

    Emmanuel Tobiloba Akinmuyiwa was a 7-year-old boy with sickle cell disease who died after developing severe anaemia during a sickle cell crisis. The report identified failures to check his haemoglobin and provide an earlier blood transfusion, and raised concerns about the lack of clear regional protocols and staff knowledge for managing sickle cell 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 clear West Midlands guidelines and protocols for the management and treatment location of patients with sickle cell disease

    Wider context from the report

    “Evidence at the inquest confirmed that there needed to be a clear protocol in the West Midlands for the management of patients with Sickle cell disease. Ordinarily they are managed at Birmingham Children's hospital. In this case as Emmanuel was admitted to Heartlands hospital various telephone calls were made to Birmingham Children's hospital. It was acknowledged in an internal investigation by Birmingham Heartlands hospital that staff had a lack of knowledge and appreciation for the signs and symptoms of a sickle cell crisis and what treatment was necessary. I was informed at the inquest that clinicians would prefer a hub and spoke approach to treatment of sickle cell disease with clear guidelines and protocols for how and where patients should be treated. I was informed that this had not happened to date due to the lack of funding available to liaise with all local hospitals and produce and put in place such protocol and guidance. A lack of guidelines and protocols for the West Midlands means future patients are at risk of death. ”

    Source location

    Emmanuel Tobiloba Akinmuyiwa · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. 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

  4. South London

    AI-generated summary

    Simon William McAndrew · 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

    Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

    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 and recognise information about psychiatric responsibility between NHS trusts

    Wider context from the report

    “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital. Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM. For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust. This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves. ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. County Durham and Darlington

    AI-generated summary

    Zeeyad Hamadi · 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

    Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

    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 system guiding privately funded transfers between hospitals

    Wider context from the report

    “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”

    Source location

    Zeeyad Hamadi · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 designated ownership and control for complex hospital transfer arrangements

    Wider context from the report

    “(4) Requests by HMP Frankland for mutual aid from prisons in London to provide bed watch office cover were unsuccessful and it was only after the intervention of the governing Governor of HMP Frankland with a senior manager at the high security estate Headquarters of the prison service that an instruction was given for a London prison to provide bed watch cover. There was a lack of understanding as to and what circumstances the transfer from Durham to London could be facilitated by an NHS ambulance, a private ambulance or an air ambulance. There was no evidence to show bad faith on the part of any of the individuals who were involved in this transfer process but there was no system in place to aid those involved in this process to guide them as to how a transfer should properly be made from an NHS hospital in one part of the country to a hospital in another part of the country where treatment was to be privately funded. There was as a result no single point of contact within the prison (either of a health care or a discipline background) who was able to take ownership of the issue, or a group of people properly designated to take control of such a situation, with the result that in conjunction with the failure for mutual aid to be given the bed watch requirements for a delay to have taken place which could have reduced the deceased’s chances of receiving treatment which may have prolonged his life. Evidence was given that notwithstanding the fact that the deceased died in October 2010 no policy or guidance has been introduced to assist either prison service staff or health care providers with the issues highlighted by this case which were described in evidence as unprecedented. Although there may be limited occasions when prisoners might have family resources to provide private medical care it is possible that more people will have the benefit of private medical insurance which may be of assistance in similar cases. The use of such private medical care covered by insurance would lead to a reduction in the cost burden imposed on the NHS. ”

    Source location

    Zeeyad Hamadi · 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

    Consult with NOMS on prisoners’ access to private healthcare and transfers from NHS care.

    Verbatim wording from the response

    “Officials have consulted with NOMS and with regard to the issue of whether a prisoner is entitled to use private healthcare, and what happens if they are using NHS services and wish to transfer to the private sector, I can confirm that it is very rare for a prisoner to seek private treatment. There are no national protocols currently in place by which a request for private treatment from a prisoner would be considered.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 3 · response
    Published 13 January 2014

    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

    Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.

    Verbatim wording from the response

    “I consider that several of the issues you have raised regarding record keeping, liaison between prison and hospital medical staff, security issues such as bed-watch and ownership of the situation at the prison, are not for my Department to respond.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 2014

    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 National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.

    Verbatim wording from the response

    “I note that you have sent a copy of this Regulation 28 report to the National Offender Management Service (NOMS) and I would expect them to properly address these issues.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 2014

    Open published response
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Data last updated 7 September 2026