Recurring concern

Unreliable hospital porter services

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First reported 1 Feb 2019•Latest report 4 May 2021

Definition

What this concern includes

Includes failures of the hospital porter service or its dedicated controls concerning porter availability, responsibility allocation, communication, escalation or coordination for patient movement or hospital operations.

Not included

  • Excludes generic staffing shortages or contingency failures that are not specifically tied to hospital porter services.
  • Excludes clinical assessment, nursing care or patient-movement hazards that do not concern porter-service provision.
  • Excludes unrelated transport, logistics or equipment failures outside the hospital porter service.
Reports
2

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2019–2021

First to latest report issue date

Stated actions
5

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.

the Shrewsbury and Telford Hospital NHS Trust1
Wye Valley 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. Shropshire, Telford and Wrekin

    AI-generated summary

    William Arthur John SIMONS · 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

    William Arthur John SIMONS died following two falls while receiving treatment at Royal Shrewsbury Hospital, with the second fall identified as more significant and preventable. Concerns included confusion and communication failures in the Tele-tracking transport system, unclear responsibilities when nursing staff were unavailable to assist a patient, and inadequate awareness of the patient's falls risk.

    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

    Tele-tracking system failing to support clear transport communication

    Wider context from the report

    “(1) The Tele-tracking system a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it. b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly. c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame. (2) Assistance. It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available. (3) Risk awareness. The porter did not know the patient’s level of risk of falls. ”

    Source location

    William Arthur John SIMONS · Prevention of Future Deaths report
    Page 1 · 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 clear porter responsibilities when nursing staff are unavailable

    Wider context from the report

    “(1) The Tele-tracking system a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it. b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly. c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame. (2) Assistance. It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available. (3) Risk awareness. The porter did not know the patient’s level of risk of falls. ”

    Source location

    William Arthur John SIMONS · 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

    Failure to provide clear allocation and communication of transport assessment responsibilities

    Wider context from the report

    “(1) The Tele-tracking system a) It was not clear what the purpose was of a doctor expressing a preferred option of transport (i.e. by trolley/bed) if that doctor did not have sufficient information to make it. b) Whilst it became clear that that option was subject to review by the nursing staff on the ward it was not clear why a doctor would not either liaise with the nursing staff or expressly make it clear that the nursing staff should make that assessment and inform the porters accordingly. c) The system on the day led to confusion and a breakdown in communication with the patient being taken instead by wheelchair with his zimmer frame. (2) Assistance. It was established that assisting a patient to move meant by a member of the nursing staff and not a porter. It should be clear what a porter is to do if no nursing staff is available. (3) Risk awareness. The porter did not know the patient’s level of risk of falls. ”

    Source location

    William Arthur John SIMONS · 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

    Put in place a radiology patient-transport Standard Operating Procedure incorporating the new transfer process.

    Verbatim wording from the response

    “• A Standard Operating Procedure (SOP) for Transporting Patients to and from Radiology has been put in place and this new process has been included in that (enclosed).”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 2 · response
    Published 5 May 2021

    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 transport roles and responsibilities in the wider Hospital Transfer Policy through the Trust ratification process.

    Verbatim wording from the response

    “• The process, including roles and responsibilities, will be included in a new wider Hospital Transfer Policy. This has been drafted and is currently going through the Trust’s ratification process.”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Recommunicate the requirement that nursing staff assist Porters with patient transfers through a Trust safety alert, meetings, and written instructions to Porters.

    Verbatim wording from the response

    “This was communicated as part of the SI and Porters DO NOT transfer patients from chair to wheelchair or bed without the assistance of a nurse when being transferred off or onto the ward.”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 2 · response
    Published 5 May 2021

    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

    Implement a radiology transfer form requiring registered-nurse assessment, documentation, and sign-off before transfer and on return.

    Verbatim wording from the response

    “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 1 · response
    Published 5 May 2021

    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

    Review the transfer form with key staff to ensure dynamic risk assessment and clear nursing documentation before patient transfer.

    Verbatim wording from the response

    “• A review of the form has taken place with all key staff, to ensure this is a dynamic risk assessment, and there is clear documentation for the RN caring for the patient prior to the patient being transferred to and from an investigation/procedure.”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 2 · response
    Published 5 May 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

    Wheelchair transport was appropriate because the patient mobilised with assistance and was comfortable sitting, although the assessment process was undocumented.

    Verbatim wording from the response

    “The mode of transport to the department for the investigation for an inpatient is specified on the form by the doctor making the request. This should be done in discussion with the nursing staff. However, the patient’s condition may change from the time of the request to the investigation being undertaken and so a further assessment should be made by the registered nurse (RN) caring for the patient at the time of transfer of the patient.”

    Source location

    2021-0133-Response-from-Royal-Shrewsbury-Hospital-Redacted
    Page 1 · response
    Published 5 May 2021

    Open published response
  2. Herefordshire

    AI-generated summary

    Mary Bertha Johnson · 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

    Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.

    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 porter availability limiting theatre operations

    Wider context from the report

    “(2) It was suggested that the availability of porters determined the ability of the hospital theatres to carry out operations ”

    Source location

    Mary Bertha Johnson · Prevention of Future Deaths report
    Page 1 · 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

    Porter availability had no material effect on the patient's outcome.

    Verbatim wording from the response

    “The investigation has established that the availability of porters had no material effect on this patient’s outcome.”

    Source location

    2019-0458-Response-by-Wye-Valley-NHS-Trust
    Page 1 · response
    Published 1 February 2019

    Open published response
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Data last updated 7 September 2026