Failure to safely coordinate transfer of urgent surgical patients
First to latest report 14 Dec 2015 — 18 Feb 2025
Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
16
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
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
Linked response
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Conduct daily face-to-face clinical assessments of surgical patients awaiting transfer to prioritise transfers and monitor blood tests.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Develop and roll out a digital tracking system monitoring referred patients’ physiology, sepsis parameters and observations for clinical-team oversight and prioritisation.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Tailor the tracking system to orthopaedic standards and complete its implementation.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Discuss implementation of the tracking system with wider specialties for surgical patients.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Implementation of surgical patient tracking is constrained by competing digital priorities and limited resources and capacity.
Unable 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
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
Inter-facility transfers requiring immediate treatment at a receiving facility are categorised by clinical condition and urgency, rather than diagnosis, as Category 2.
Disputes 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.
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Betsi Cadwaladr University LHB
Re-share the agreed transfer process with all Integrated Health Communities and obtain confirmation that it has been cascaded.
Betsi Cadwaladr University LHB
Confirm site management teams at all acute sites as the single contact point for emergency transfers.
Betsi Cadwaladr University LHB
Review the Patient Transfer Procedure (NU19) led by the Head of Nursing and Head of Patient Safety.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Betsi Cadwaladr University LHB
Mrs Owens did not meet current ACCTS referral or transfer criteria because the proposed transfer was ward-to-ward without identified critical care needs.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Betsi Cadwaladr University LHB
ACCTS is commissioned only for patients requiring critical care; non-critical ward-to-ward transfers should be referred to the Welsh Ambulance Service Trust.
Redirects 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.
Linked responses
Department of Health and Social Care
NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Department of Health and Social Care
Provide funding to continue enhanced hospital discharge arrangements and maintain safe, timely patient discharge over winter.
Department of Health and Social Care
Provide NHS Long Term Plan funding for primary and community care by 2023/24.
Department of Health and Social Care
Roll out support for care home residents so more people can receive care in their communities.
NHS Greater Manchester Integrated Care Board
Continue developing the Urgent and Emergency Care Operational Hub’s methods for managing demand and patient flow to reduce emergency department crowding.
NHS Greater Manchester Integrated Care Board
Implement Greater Manchester Discharge to Assess guidance, including standard referral, rapid triage, testing and PPE, medication supply, and next-day follow-up processes.
NHS Greater Manchester Integrated Care Board
Create additional community-based capacity to support discharge pathways and improve acute-hospital patient flow.
NHS Greater Manchester Integrated Care Board
Review community-based capacity to support discharges.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Stockport health system partners are responsible for taking action to address urgent and emergency care safety concerns.
Redirects 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.
Linked response
Guy'S and St Thomas' NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Guy'S and St Thomas' NHS Foundation Trust
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.
Guy'S and St Thomas' NHS Foundation Trust
Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Guy'S and St Thomas' NHS Foundation Trust
Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.