Recurring concern

Unreliable cross-Trust transfer arrangements for complex patients

Get email alerts

Request correction

First reported 17 Jun 2014•Latest report 6 May 2026

Definition

What this concern includes

Includes failures in the end-to-end cross-Trust transfer process for complex patients, including guidance, planning, responsibility allocation, transport arrangements, information transfer, receiving-service coordination and continuity-of-care safeguards.

Not included

Excludes transfers within a single Trust unless the report explicitly links them to the same cross-Trust transfer arrangement.
Excludes generic patient-flow, discharge or transport deficiencies that are not specifically part of transferring a complex patient between NHS Trusts.
Excludes failures concerning routine transfers of patients without materially complex care or coordination needs.
Excludes generic cross-agency communication or accountability failures where no cross-Trust patient-transfer concern is identified.

Reports: 2
Individual concerns: 5
Date range: 2014–2026
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Coventry and Warwickshire Partnership NHS Trust1

NHS England1

Office of the Chief Coroner1

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.

6 May2026
Hampshire, Portsmouth and Southampton
Concerns raised4
1. Lack of national guidance for cross-Trust transfer of complex cases
2. Lack of training on national guidance for complex case transfers
3. Failure to conduct risk assessments at the time of complex case transfer
1. Lack of senior management oversight of complex case transfers
This report raised 5 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 1
1. Action
  Publish the Mental Health Personalised Care Framework, including expectations for transfers of care between services.
  Stated by NHS EnglandStated planned
AI-generated summary

Sunny Elise EYMOND · 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

Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.

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
Lack of national guidance for cross-Trust transfer of complex cases
Wider context from the report
“1. While the two trusts involved in the inquest (Southern Health and Avon & Wiltshire Mental Health Partnership NHS Trust) have undertaken reviews, learned lessons and implemented changes following Sunny’s death, the same has not happened at a national level/England wide Trust level. 2. Firstly, I am concerned that a risk of death may arise in the future if the concerns raised are not addressed more widely and brought to the attention of other Trusts and consideration is not given to the production of national guidance on cross Trust transfer of complex cases, particularly those involving patients with a diagnosis of an eating disorder and complex Post Traumatic Stress Disorder/Emotionally Unstable Personality Disorder/complex emotional needs. ”
Source location
Sunny Elise EYMOND · Prevention of Future Deaths report
Page 4 · 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 training on national guidance for complex case transfers
Wider context from the report
“4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for: a) Senior management oversight of the transfer b) Risk assessments at the time of transfer c) Clear escalation procedures if concerns are raised during the transfer and d) Training on any such national guidance ”
Source location
Sunny Elise EYMOND · Prevention of Future Deaths report
Page 5 · 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 conduct risk assessments at the time of complex case transfer
Wider context from the report
“4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for: a) Senior management oversight of the transfer b) Risk assessments at the time of transfer c) Clear escalation procedures if concerns are raised during the transfer and d) Training on any such national guidance ”
Source location
Sunny Elise EYMOND · Prevention of Future Deaths report
Page 5 · 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 senior management oversight of complex case transfers
Wider context from the report
“4. There is currently no national guidance on how best to manage and plan for Trust to Trust transfers of highly complex cases (in particular those involving patients with both a diagnosed eating disorder such as AN and complex emotional needs). Guidance is therefore required as to the need for: a) Senior management oversight of the transfer b) Risk assessments at the time of transfer c) Clear escalation procedures if concerns are raised during the transfer and d) Training on any such national guidance ”
Source location
Sunny Elise EYMOND · Prevention of Future Deaths report
Page 4 · 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
Publish the Mental Health Personalised Care Framework, including expectations for transfers of care between services.

Verbatim wording from the response
“NHS England expects to publish the Mental Health Personalised Care Framework shortly. The Mental Health Personalised Care Framework sets out the approach and related principles and actions for delivering personalised care for adults and older people with severe mental health problems. The framework includes a section on expectations for any transfer of care between services including the following:”

Source location
Response from NHS England
Page 1 · response
Published 2 July 2026
Open published response
17 Jun2014
Norfolk
Concerns raised1
1. Failure to plan patient transfers to another Trust in advance
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · 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

Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

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 plan patient transfers to another Trust in advance
Wider context from the report
“I heard at the Inquest from the Acting Deputy Service Manager of Norfolk & Suffolk NHS Foundation Trust’s Access & Assessment Team. In her evidence she stated that in her experience she would have expected the Warwickshire & Coventry Partnership Trust to have made a direct written referral Trust to Trust rather then via the GP, given the complex needs and history of Sol and that this should have been planned in advance. Whilst it can not be known whether had such referral been made the outcome for Sol would have been different, I am nevertheless concerned that a similar circumstance to arise in the future an preventable death might occur and there is a continuing risk that other deaths could occur which could be avoided. I was therefore concerned that procedures for transferring a patient to another Trust should be reviewed by the Warwickshire & Coventry Partnership Trust. ”
Source location
SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised4

Lack of national guidance for cross-Trust transfer of complex cases

Lack of training on national guidance for complex case transfers

Failure to conduct risk assessments at the time of complex case transfer

Lack of senior management oversight of complex case transfers

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.1

Concerns raised1

Failure to plan patient transfers to another Trust in advance

Actions described in response 1