Barnabas Newlyn · Prevention of Future Deaths report

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Issued 19 Nov 2013•London Inner (North)

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

Described in responses

Recipients and published responses

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 raised1

  1. Insufficient timeliness of road transfer for time-sensitive critical care patients

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. NHS England

    Mobilise commissioning arrangements to discuss and standardise neurosurgical transfer protocols between local receiving units and ambulance services.

  2. NHS England

    Commission a report evaluating the feasibility of integrating air ambulance services more closely into the critical care neurosurgery pathway.

  3. NHS England

    Issue interim guidance to acute hospitals covering equipment readiness for paediatric and adult road or air transfers.

  4. NHS England

    Establish a programme to provide retrieval training for critical care staff in district general hospitals.

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

  1. NHS England

    Air ambulance integration cannot yet be specified because availability is unreliable and evidence does not establish that air transfer would be quicker.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Insufficient timeliness of road transfer for time-sensitive critical care patients

Wider context from the report

“In the case of Barnabas Newlyn there were particular difficulties in arranging timely transfer, and earlier transfer would have been unlikely to affect the outcome. However, the Court heard that even without such difficulties the time taken to travel by road from QEQM to Great Ormond Street Hospital does not afford a realistic opportunity to save the life of a patient needing time sensitive critical care transfer, especially neurosurgical emergencies. This may be an issue for other similarly placed hospitals elsewhere in the country where they need to transfer patients to specialist facilities at some distance. Whilst recognising that helicopter services are not directly managed or funded by NHS England, it may be helpful and appropriate for healthcare staff needing urgent transfer to start by attempting to secure air transfer. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Mobilise commissioning arrangements to discuss and standardise neurosurgical transfer protocols between local receiving units and ambulance services.

Verbatim wording from the response

“Secondly we are in the process of mobilising commissioning arrangements in particular the Paediatric Neuroscience Clinical Reference Group of NHS England and the South London and Kent Trauma Network (run from Kings College Hospital – adults only) for a more comprehensive discussion about standardising protocols between the local neurosurgical receiving units (Kings College Hospital for adults and Great Ormond Street for paediatrics). These arrangements will need to encompass at least two”

Source location

2013-0382-Response-by-NHS-England
Page 3 · response
Published 13 November 2013

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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

Commission a report evaluating the feasibility of integrating air ambulance services more closely into the critical care neurosurgery pathway.

Verbatim wording from the response

“Finally we will commission a report that looks specifically at the feasibility of building the air ambulance service more closely into the critical care neurosurgery pathway in these circumstances.”

Source location

2013-0382-Response-by-NHS-England
Page 4 · response
Published 13 November 2013

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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

Issue interim guidance to acute hospitals covering equipment readiness for paediatric and adult road or air transfers.

Verbatim wording from the response

“Firstly in the next month we will issue interim guidance to acute hospitals which will contain the following:”

Source location

2013-0382-Response-by-NHS-England
Page 3 · response
Published 13 November 2013

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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

Establish a programme to provide retrieval training for critical care staff in district general hospitals.

Verbatim wording from the response

“3. Training will be offered to critical care staff in all district general hospitals in retrieval. This is currently a requirement of doctors in training in critical care to receive. However it is not clear the degree to which these skills are available at all times within all of our local hospitals and a programme will be established to ensure that it is so. This programme will be established within the next month.”

Source location

2013-0382-Response-by-NHS-England
Page 3 · response
Published 13 November 2013

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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

Air ambulance integration cannot yet be specified because availability is unreliable and evidence does not establish that air transfer would be quicker.

Verbatim wording from the response

“The availability of an air ambulance resource was discussed in some detail. The NHS in Kent, Surrey and Sussex does have access to an air ambulance service and recently that service received clearance to fly outside the hours of daylight. It was noted however that there are difficulties in building the air ambulance service reliably into the critical care transfer pathway. Firstly the air ambulance is tasked at present to be available to respond to severe road traffic crashes. There is a single aircraft and it cannot be relied upon to be available at all time for reasons of other operational distractions or maintenance. In addition it is not clear from the evidence or experience of senior clinicians that an air ambulance transfer to Great Ormond Street would have been quicker than the 77 minutes that the road ambulance took to transfer the patient to Great Ormond Street.”

Source location

2013-0382-Response-by-NHS-England
Page 3 · response
Published 13 November 2013

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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