PFD report

Peter David KNIGHT · Prevention of Future Deaths report

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Issued 18 Mar 2019•Norfolk

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Delays in completing the policy for transferring oxygen-dependent patients
  2. Failure to commence a trial of new patient-transfer documentation
    Part of recurring concern: Unreliable healthcare patient transfer processes
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 recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Redesign, approve and barcode the SBAR patient-transfer handover tool.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.
  2. Action

    Ratify the combined inter- and intra-hospital Transfer of Patients Policy.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.
  3. Action

    Trial the amended escort-assessment guide and SBAR transfer tool in high-risk clinical areas.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Acute-area feedback did not identify a need to alter the finalised transfer policy further.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in completing the policy for transferring oxygen-dependent patients

Wider context from the report

“At the inquest I was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant. It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, I wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy. Not having heard from the Trust, my Officer contacted the Trust today. A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced. Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April, I am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to commence a trial of new patient-transfer documentation

Wider context from the report

“At the inquest I was satisfied that the Trust took the concerns raised seriously and was in the process of reviewing its Policy with regard to the transfer of patients, particularly those who are oxygen dependant. It was anticipated the Policy would be completed by the end of February 2019. In the circumstances, I wrote to the Trust asking them to write to me by 15 March 2019 with full details of the Policy. Not having heard from the Trust, my Officer contacted the Trust today. A response has been received indicating that new documentation has now been generated but a trial into its use has not yet commenced. Although it is stated that a trial is due to be started within the week and that if effective, implementation will be ratified by end of April, I am concerned that the inquest concluded in January 2019 and the Policy was not completed in the timescale indicated and agreed at the inquest and its trial has not yet commenced. ”

Is this part of a recurring concern?

Yes — Unreliable healthcare patient transfer processes.

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

Redesign, approve and barcode the SBAR patient-transfer handover tool.

Verbatim wording from the response

“12. The group researched and designed a handover sheet for all intra-hospital patients as the current documentation did not meet requirements. The guide for registered nurses to assess if the patient requires an escort was also amended and more detailed for patients with a lower News 2 score. The guide also suggests equipment for transfer of patients. The group decided that one document for all transfers would be of benefit and add in electronic links to specific documents separate from the policy would work well. This will enable specific documents to change and the policy link will always be as up to date as possible. This has delayed completion of the policy due to some policies being accessible on the intranet. Many emails were shared between meetings with various versions of documents for comment.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 4 · response
Published 15 July 2019

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

Ratify the combined inter- and intra-hospital Transfer of Patients Policy.

Verbatim wording from the response

“I’m writing to say that I am now able to respond to your Regulation 28 report dated 18 March with respect to the Transfer of Patients Policy. In order to do this I attach a timeline of the key events which have taken place since Mr Knight’s sad death and a copy of the policy itself which was ratified at the Clinical Governance Committee meeting on 7th May.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 1 · response
Published 15 July 2019

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

Trial the amended escort-assessment guide and SBAR transfer tool in high-risk clinical areas.

Verbatim wording from the response

“14. 1st April 2019 – ‘Guide for Escort required for patient Transfers in hospital’ and ‘Patient Transfer Handover SBAR¹ tool’ out to trial during April in the high risk areas of Assessment Zone, Acute Medical Unit, Surgical Assessment unit and A&E before going Trust Wide. These areas found that the SBAR forms are working well and will to continue using the new forms beyond the pilot stage.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 5 · response
Published 15 July 2019

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

Launch the adapted SBAR patient-transfer tool Trust-wide after pilot feedback and audit results.

Verbatim wording from the response

“14. 1st April 2019 – ‘Guide for Escort required for patient Transfers in hospital’ and ‘Patient Transfer Handover SBAR¹ tool’ out to trial during April in the high risk areas of Assessment Zone, Acute Medical Unit, Surgical Assessment unit and A&E before going Trust Wide. These areas found that the SBAR forms are working well and will to continue using the new forms beyond the pilot stage.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 5 · response
Published 15 July 2019

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

Acute-area feedback did not identify a need to alter the finalised transfer policy further.

Verbatim wording from the response

“• None of the feedback from the acute areas will mean that the finalised policy will need to be altered in any way.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 6 · response
Published 15 July 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Carry out a further compliance audit two months after the Trust-wide transfer-tool launch.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2019.
  2. 2

    Update critically ill patient transfer training to prohibit transfers on Hi Flo Airvo2 machines without battery backup.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.
  3. 3

    Distribute the transfer risk-assessment matrix to ward managers and matrons.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Battery packs are not a straightforward technical solution for oxygen-dependent transfers because they have caused problems and incidents elsewhere.

    Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Carry out a further compliance audit two months after the Trust-wide transfer-tool launch.

Verbatim wording from the response

“16. Full launch of the adapted SBAR patient transfer tool Trust-wide in June following the pilot feedback and audit results (audit completed audit 3rd May). In addition a further compliance audit and use of the document will be carried out two months after the Trust-wide launch.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 5 · response
Published 15 July 2019

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

Update critically ill patient transfer training to prohibit transfers on Hi Flo Airvo2 machines without battery backup.

Verbatim wording from the response

“1. 7th September 2018 – Transferring the Critically Ill Patient Training study event – Facilitated by ████████ – Attended by Anaesthetic Doctors, Operating department assistants, Nurses from all areas. The “Do not transfer patients on Hi Flo airvo2 machine due to no battery back-up” decision post Mr Knight’s case was added in to the programme information.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 3 · response
Published 15 July 2019

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

Distribute the transfer risk-assessment matrix to ward managers and matrons.

Verbatim wording from the response

“4. 16th October 2018 – Matron ████████ sent out Risk Assessment Matrix for transferring patients to all Ward mangers and Matrons.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 3 · response
Published 15 July 2019

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

Battery packs are not a straightforward technical solution for oxygen-dependent transfers because they have caused problems and incidents elsewhere.

Verbatim wording from the response

“• Benchmarking during this review period has revealed that other acute trusts have been using battery packs for oxygen-necessary transfers and these have proved problematic and given rise to incidents, leading to the conclusion that there is no easy cure-all technical solution.”

Source location

2019-0219-Response-by-The-Queen-Elizabeth-Hospital-Kings-Lynn
Page 6 · response
Published 15 July 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026