First reported 29 Jan 2015•Latest report 26 Nov 2021
Definition
What this concern includes
Includes failures in the dedicated ambulance-to-emergency-department handover process involving the Patient Report Form or equivalent pre-hospital information, including availability to receiving staff, access to electronic or paper forms, review before or during triage, contextual integration, documentation of review and resolution of access problems.
Not included
Excludes failures in ambulance information transfer within ambulance services when no Emergency Department receiving or triage interface is involved.
Excludes generic clinical handover, record access or electronic-record failures without a material ambulance-to-emergency-department patient-information handover context.
Excludes failures to act on complete and timely pre-hospital information after it has been reliably received and reviewed.
Excludes clinical assessment, treatment or triage failures where the ambulance handover information process itself was reliable.
Reports
4
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2015–2021
First to latest report issue date
Stated actions
12
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.
Department of Health and Social Care2
NHS England2
East Midlands Ambulance Service NHS Trust1
Family of the deceased1
Home Office1
National Police Chiefs’ Council1
NHS Nottingham and Nottinghamshire Integrated Care Board1
North West Ambulance Service NHS Trust1
Nottingham University Hospitals NHS Trust1
Sherwood Forest Hospitals NHS Foundation Trust1
Somerset NHS Foundation Trust1
Stockport NHS Foundation Trust1
Weightmans LLP1
Yeovil District Hospital1
NHS trust4
Executive non-departmental public body2
Ministerial department2
Healthcare site1
Integrated care board1
Limited liability partnership1
National policing body1
Type not available1
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.
Dorset
Concerns raised1
Failure of Emergency Department staff to access vital pre-admission and paramedic records
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.3
Action
Convert ambulance and other pre-hospital information into PDF documents stored in the hospital electronic record for Emergency Department access.
Stated by Yeovil District HospitalStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
Action
Share the patient story and learning from the incident with Emergency Department staff.
Stated by Yeovil District HospitalStated completedThe respondent said that this action was complete when they made their response on 29 November 2021.
Action
Provide ongoing education to Emergency Department staff to improve access to relevant clinical information.
Stated by Yeovil District HospitalStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The hospital-record access concern was considered answered by the Trust’s response and did not require a national response.
Stated by NHS EnglandNo action considered necessaryThe respondent said that no further action was needed.
Position
A fully automated system giving hospital staff direct access to ambulance records was not yet possible, so an interim measure was used.
Stated by Yeovil District HospitalUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Nottinghamshire
Concerns raised2
Failure to review the electronic Patient Report Form during emergency department handover
Failure to resolve electronic Patient Report Form access problems
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.9
Action
Reinforce to receiving staff the importance of reviewing EMAS electronic patient report forms alongside verbal handover.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Enable NUH Digital Services to create EMAS ePRF accounts directly and issue access to staff requiring it.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Install EMAS ePRF access links on NUH clinical desktops and Nervecentre.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Brief NUH Heads of Service to establish processes for reviewing EMAS ePRFs for patients received directly from ambulance crews.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Provide SFH staff with an interim process to access, convert and save EMAS ePRFs into SystmOne after patient arrival.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Implement automated EMAS transmission of draft and final ePRF data to receiving hospital informatics systems without additional logins.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
Action
Implement NUH integration to transfer finalised EMAS ePRFs into CareCentric and DHR for immediate clinical review and record visibility.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
Action
Develop and implement the SFH ePRF web viewer and automated SystmOne integration for clinical access without additional login.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
Action
Add finalised SFH ePRFs to CareCentric so staff can view records for patients initially taken to either hospital.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
SFH cannot control automated ePRF integration because it depends on NHS Digital standards development and subsequent implementation by TPP.
Stated by East Midlands Ambulance Service NHS Trust and Nottingham University Hospitals NHS Trust and Sherwood Forest Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised2
Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Department considers the concerns matters for local comment and resolution rather than national action.
Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.
Position
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Failure to make the PRF available to the doctor providing emergency care
Failure to make the ambulance Patient Report Form available to the triage nurse before triage
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The ambulance information system worked: the PRF was scanned before the doctor assessed the patient.
Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures in the dedicated ambulance-to-emergency-department handover process involving the Patient Report Form or equivalent pre-hospital information, including availability to receiving staff, access to electronic or paper forms, review before or during triage, contextual integration, documentation of review and resolution of access problems.
