Recurring concern

Unreliable transfer arrangements for at-risk mental health patients

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First reported 24 Dec 2015•Latest report 25 Aug 2022

Definition

What this concern includes

Includes failures in dedicated transfer policies, assessment tools, consultation requirements, escort arrangements and related controls for transferring or moving at-risk mental health patients, including patients awaiting mental-health assessment or being transferred within a hospital.

Not included

  • Excludes generic patient-transfer deficiencies without an at-risk mental-health-patient context.
  • Excludes ordinary cross-Trust or inter-hospital transfer failures unless the assertion specifically concerns the same at-risk mental-health transfer process.
  • Excludes failures in mental-health assessment, treatment or detention after a transfer process has operated reliably.
  • Excludes generic training, documentation or staffing deficiencies unless they directly impair the dedicated transfer arrangements for at-risk mental health patients.
Reports
2

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2015–2022

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.

Bedfordshire Hospitals NHS Foundation Trust1
James Paget University Hospital1
Norfolk and Norwich University Hospital1
Norfolk and Suffolk NHS Foundation Trust1
The Queen Elizabeth Hospital, King's Lynn1

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. Bedfordshire and Luton

    AI-generated summary

    Yuksel Bedri ISMAIL · 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

    Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

    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 assess the needs of at-risk patients in transfer arrangements

    Wider context from the report

    “1. The Court was told that SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made. Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue: - Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements. ”

    Source location

    Yuksel Bedri ISMAIL · Prevention of Future Deaths report
    Page 2 · 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 consult PLS staff about escort and transfer arrangements

    Wider context from the report

    “1. The Court was told that SI investigation had not been completed by the Trust in this case; however, the PEARL Meeting on 3 December 2021 acknowledged that "the current transfer policy needs reviewing...the transfer policy implemented around the mental health patients should be prioritised as there are risks involving patients and staff, all depending on the assessment of the patient". Despite this and ELFT's own SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) having highlighted the need for PLS staff to be involved in any decision regarding patients waiting for MHA assessment, or who may need to be conveyed to another area within the hospital site as 'such patients are high risk and often unpredictable', by the start of the Inquest held on 24 August 2022, there was no evidence of Bedford Hospitals NHS Trust's acceptance of the recommendations made. Whilst at lunchtime on the day of the Inquest itself, the Court was provided with a draft of a new Transfer Policy, this Policy still did not appear to have addressed the main issue: - Whilst it includes "Confused, disorientated, self-harming, suicidal or displaying erratic or aggressive behaviours" and "patients at risk of absconding" in the list of 'At risk' patients in Section 3, the needs of such patients are still not addressed in the Assessment Tool (Appendix 4) nor is the need for consultation with the PLS staff about any of the escort/transfer arrangements. ”

    Source location

    Yuksel Bedri ISMAIL · 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

    Implement the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.

    Verbatim wording from the response

    “We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.”

    Source location

    Response from Bedfordshire Hospital NHS Foundation Trust
    Page 1 · response
    Published 3 October 2022

    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

    Continue joint Trust and ELFT work to embed transfer protocols and improve safety for mental health patient transfers.

    Verbatim wording from the response

    “Collaborative work between the Trust and ELFT will also be ongoing to ensure embedding of protocols and increased safety when it is necessary for mental health patients to be transferred.”

    Source location

    Response from Bedfordshire Hospital NHS Foundation Trust
    Page 2 · response
    Published 3 October 2022

    Open published response

  2. Norfolk

    AI-generated summary

    CHRISTOPHER JONATHAN HIGGINS · 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

    Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

    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 of escort policy and planning to address inter-service patient transfers

    Wider context from the report

    “(2) The Escort Policy does not include information relating to the transfer of patients from one place to another (in this case from an Acute Hospital to the Fermoy Unit) when other services are involved, for instance the Police. In particular, Mr Higgins who had been acting in an unpredictable, and paranoid manner, was put into a cage at the rear of the Police van with three Police Officers, with no Mental Health staff to accompany him. The evidence did not reveal that this had been considered by the Mental Health staff previously attending to Mr Higgins; ”

    Source location

    CHRISTOPHER JONATHAN HIGGINS · 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

    Strengthen policy direction so staff accompany patients during transfers wherever possible, with safety-based decisions made with other involved services.

    Verbatim wording from the response

    “Your report reflected the fact that Mr Higgins was transferred in the Police van back to the Fermoy Unit without a member of mental health staff present. Accepting that in Mr Higgins’s case the travel time and distance was small (within the site), the Trust acknowledges how important this can be for the patient. Therefore the Trust will be strengthening its policy direction (the policy is further”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 1 · response
    Published 24 December 2015

    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

    Mental health staff may be unable to accompany patient transfers in limited instances where safety makes accompaniment impossible.

    Verbatim wording from the response

    “referenced below) that staff should wherever possible, accompany the patient during the transfer. There may be some limited instances where this is not possible on the grounds of safety but decisions would be made in liaison with other service involved.”

    Source location

    2015-0480-Response-by-Norfolk-and-Suffolk-NHS-Trust
    Page 2 · response
    Published 24 December 2015

    Open published response
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Data last updated 7 September 2026