First reported 14 Dec 2015•Latest report 18 Feb 2025
Definition
What this concern includes
Includes failures of controls dedicated to the end-to-end transfer of urgent surgical patients, including monitoring while awaiting transfer, surgical bed capacity, acceptance decisions and communication needed to arrange timely transfer.
Not included
Excludes generic monitoring, staffing or capacity deficiencies not explicitly tied to transfer of urgent surgical patients.
Excludes failures in unrelated patient-transfer pathways, such as mental-health, maternity or non-surgical transfers.
Excludes clinical treatment failures occurring after transfer has been completed.
Reports
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
16
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.
Betsi Cadwaladr University LHB1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
NHS England1
The Hospital of St Thomas the Apostle in Doncaster1
Executive non-departmental public body1
Health-system partnership1
Local health board1
Ministerial department1
NHS trust1
Registered provider of social housing1
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.
Nottinghamshire
Concerns raised2
Lack of a system for monitoring clinical parameters of urgent surgical patients awaiting transfer
Lack of a system for prioritisation of urgent surgical patients awaiting transfer
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Develop and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Tailor the tracking system to orthopaedic standards and complete its implementation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Discuss implementation of the tracking system with wider specialties for surgical patients.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implementation of surgical patient tracking is constrained by competing digital priorities and limited resources and capacity.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East Sussex
Concerns raised1
Failure to classify transfers for aortic dissection requiring emergency surgery as category 1
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Inter-facility transfers requiring immediate treatment at a receiving facility are categorised by clinical condition and urgency, rather than diagnosis, as Category 2.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Wales (East and Central)
Concerns raised1
Failure to book urgent vascular surgery transfers with the Adult Critical Care Service Cymru
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Re-share the agreed transfer process with all Integrated Health Communities and obtain confirmation that it has been cascaded.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 4 April 2024.
Action
Confirm site management teams at all acute sites as the single contact point for emergency transfers.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 April 2024.
Action
Review the Patient Transfer Procedure (NU19) led by the Head of Nursing and Head of Patient Safety.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 4 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Mrs Owens did not meet current ACCTS referral or transfer criteria because the proposed transfer was ward-to-ward without identified critical care needs.
Stated by Betsi Cadwaladr University LHBDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
ACCTS is commissioned only for patients requiring critical care; non-critical ward-to-ward transfers should be referred to the Welsh Ambulance Service Trust.
Stated by Betsi Cadwaladr University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of surgical bed capacity delaying transfer from the Emergency Department
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
Action
Provide NHS Long Term Plan funding for primary and community care by 2023/24.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
Action
Roll out support for care home residents so more people can receive care in their communities.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 1 October 2020.
Action
Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.
Action
Implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, testing and PPE, medication supply, and next-day follow-up processes.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
Action
Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 1 October 2020.
Action
Review community-based capacity to support discharges.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Central and South East Kent
Concerns raised1
Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
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.
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
Action
Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
Stated by Guy'S and St Thomas' NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 December 2015.
Action
Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Stated by Guy'S and St Thomas' NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Stated by Guy'S and St Thomas' NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of controls dedicated to the end-to-end transfer of urgent surgical patients, including monitoring while awaiting transfer, surgical bed capacity, acceptance decisions and communication needed to arrange timely transfer.
