There could be “national and systemic issues” with the transfer of seriously ill patients between hospitals, the new Healthcare Safety Investigation Branch’s first report has said.

The patient safety body has published its first interim report after launching a full investigation into the death of 54 year old man in April.

The patient died while being rushed from a hospital emergency department to a specialist centre for life saving surgery to treat a tear in a major artery.

The report, published today, said while the man’s condition was serious and carries a high mortality rate “there were concerns that the communication and decision making across organisational boundaries, involving local and specialist centres, may have impacted on the patient’s care”.

It added: “Evidence gathered from academic and statistical sources suggested that this pathway was not an isolated incident and that it represented a national and systemic issue.

“There are potential systemic issues relating to transferring seriously ill patients between local NHS acute trusts and specialist centres. Opportunities exist for the HSIB to develop and influence learning at a national level.”

HSIB will look at the circumstances of the individual case but also examine the wider NHS and whether there are gaps that leave patients at risk. The interim report is designed to explain the scope of its investigation and to inform the NHS and the public.

None of the hospitals or organisations involved in the incident have been named by HSIB but the report does detail the circumstances of the man’s death and appeals for information that may help its investigation.

The branch said the man had developed chest pain while exercising and after calling 111 was taken by ambulance to the local district general hospital where an aortic dissection was confirmed.

It added: “An immediate decision was taken to transfer the patient to a specialist centre for urgent surgery. An ambulance crew arrived at the DGH to conduct the transfer. The patient remained in his clothes with one 20 gauge cannula inserted. He moved himself to the ambulance trolley unaided and was taken to the ambulance. No additional medical or nursing escort was provided during the ambulance transfer. The patient’s partner accompanied the crew during the transfer.”

Thirteen minutes into the journey the man suffered a cardiac arrest and the ambulance crew started resuscitation.

The report said: “En route, the crew contacted their control room with further calls made between the ambulance control, the specialist centre and a second trust’s emergency department which was on the route to the specialist centre. After advice from control the ambulance proceeded to the second trust’s emergency department in an attempt to stabilise the patient. However, further discussions between the specialist centre and the ED meant that on arrival the crew were redirected to the specialist centre.

“The crew contacted the specialist centre again as the ambulance continued its journey. They were subsequently advised that because the patient had been in cardiac arrest for thirty minutes, his condition was not survivable. The crew returned to the second trust’s ED where the patient was confirmed deceased.”

HSIB said it had identified several safety issues from its initial investigation that will be examined in detail. These include:

  • Recognition and management of conditions that are both uncommon and difficult to diagnose.
  • Standardised pre-alert, handover and other communication tools.
  • Decision making priorities surrounding the patient transfer.
  • Medical and nursing staff accompanying crews during ambulance transfers.
  • The involvement of a number of different organisations in the decision making process.

The report said: “The HSIB investigation will continue to explore the identified safety issues and welcomes further information that may be relevant, regardless of source. HSIB will report any significant developments as the investigation progresses.”

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