Recurring concern

Failure to provide timely non-emergency patient transfers

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First reported 24 Jan 2018•Latest report 19 Jul 2018

Definition

What this concern includes

Includes failures of non-emergency patient-transfer provision, including insufficient conveying capacity, missed collection or response standards, unreliable booking or dispatch arrangements, and delays in completing transfers when these directly concern timely non-emergency patient transport.

Not included

  • Excludes emergency ambulance response, emergency call handling and urgent ambulance attendance concerns.
  • Excludes hospital handover or admission delays occurring after a non-emergency transfer has reached its destination.
  • Excludes clinical escort, transfer equipment or clinical monitoring failures unless the shared unsafe condition is specifically the timely provision of the non-emergency transfer service.
  • Excludes generic transport-resource or staffing deficiencies where their effect on non-emergency patient-transfer provision is not identified.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2018

First to latest report issue date

Stated actions
3

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 Cornwall and the Isles of Scilly Integrated Care Board1
NHS Dorset Integrated Care Board1
NHS Staffordshire and Stoke-on-Trent Integrated Care Board1

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. Cornwall and Isles of Scilly

    AI-generated summary

    William George Irvin Watson · 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 George Irvin Watson was admitted with worsening angina, underwent triple coronary artery bypass surgery, and experienced post-operative complications including an infected sternal wound. He died after difficulties and delays in emergency, high-dependency and non-emergency patient transfers. The principal concerns were inadequate ambulance and patient-transport resources, performance gaps, and the potential risk of avoidable deaths or deterioration when transfers are delayed.

    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 meet non-emergency patient transfer collection standards

    Wider context from the report

    “I was told at inquest that this service, commissioned by NHS Kernow, was being provided by a company called Eezel. I was further advised that its performance requirements are to collect 95% of patients within 1 hour and for short notice bookings, 50% were to be collected with 1 hour and 95% within 2 hours. I was informed that these targets are not being met. The inquest was advised that a new service provider will be taking on this business from April 2019. Of great concern to me was the revelation made at inquest that there are currently no compliant bids. It seems obvious that a patient who would ordinarily require a non-emergency transfer but who is kept waiting beyond acceptable performance standards may deteriorate and potentially have their life put at risk. ”

    Source location

    William George Irvin Watson · 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

    Continue working with the transport provider and health system to manage demand and capacity and achieve required collection standards.

    Verbatim wording from the response

    “E-zec Medical Services has made significant improvements over the last 12 months and is currently on target to meet their trajectory of improvement in order to meet the required standards. NHS Kernow continues to work with the provider and the health system to ensure demand and capacity is manged in order to achieve these standards.”

    Source location

    2018-0237-Response-by-Kernow-Clinical-Commissioning-Group2
    Page 3 · response
    Published 23 September 2018

    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

    Kernow CCG, as commissioner, is responsible for addressing concerns about High Dependency Transport and non-emergency transfers.

    Verbatim wording from the response

    “The specific details regarding this case regarding the High Dependency Transport and the Non-emergency transfers will be addressed directly by Kernow CCG as the commissioner of those services, therefore our response will focus on providing you with further details regarding the Emergency Ambulance transport contract that we collaboratively commission.”

    Source location

    2018-0237-Response-by-Dorset-Clinical-Commissioning-Group
    Page 1 · response
    Published 23 September 2018

    Open published response
  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Reginald George KEY · 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

    Reginald George KEY underwent surgery and was discharged from hospital on 1 December 2016. He was reportedly very unwell when delivered home after a delay in patient transport and was readmitted on 4 December with sepsis. He underwent further procedures and died on 10 December 2016; concerns were raised about his discharge condition, the delay in transport, and whether his deterioration could have been identified or whether paramedics could have returned him to hospital.

    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

    Delays in patient transport home

    Wider context from the report

    “• The deceased had undergone surgery and was apparently discharged from the Royal Stoke University Hospital at 6pm on 1st December 2016. He was collected by patient transport. Clinicians tell me he was well on discharge. He was apparently deliver home at 10pm some 4 hours later when he was described as being very unwell with paramedics commenting that he should not have been discharged and that they had to carry him into the house. Family noted there were other patients in the transport vehicle awaiting return home. • Family and clinicians raised concerns about the length of time it had apparently taken to deliver him home and whether or not his deteriorating condition was or could have been spotted and whether there was an option for paramedics to return him to the hospital. He was returned to hospital very unwell on the 4th December 2016. ”

    Source location

    Reginald George KEY · 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

    Instruct the provider to produce an action plan addressing the identified patient transport safety measures.

    Verbatim wording from the response

    “Assurances Undertaken to Prevent Future Deaths To address the Coroner’s concerns we have instructed the provider to act upon the findings and include in their action plan the following:”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    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 provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.

    Verbatim wording from the response

    “We have instructed the provider to produce an action plan to address these matters. This plan will be reviewed in detail at the next provider contract and quality meeting in April 2018 by my commissioning and quality teams and will be monitored at this meeting until all actions are concluded and agreed between the provider organisation and the CCGs.”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 3 · response
    Published 20 March 2018

    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

    Transport records contradict the reported four-hour journey and record no observed deterioration or route deviation.

    Verbatim wording from the response

    “17:16 and show that he had been collected by the crew at 17:50. The PTS crew had left the hospital at 18:09 and Mr Key arrived back to his home address in Hednesford at 19:15. We have confirmed that the crew consisted of two patient transport assistants and that these were not paramedics. The PTS service have no record of any concerns being raised by their crew under their deteriorating patient policy and no indication that the crew deviated from the plan as indicated by their transport monitoring system.”

    Source location

    2018-0025-Response-by-Cannock-Chase-CCG-NHS-Trust
    Page 2 · response
    Published 20 March 2018

    Open published response
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Data last updated 7 September 2026