Systemic problems found in emergency patient transfers

The report focussed on the case of a critically ill man with a tear in his aorta who died while being transferred from a district general to a tertiary centre.

However, its findings go further than this individual case. It said: “It would be beneficial for formal governance arrangements to be established to oversee the transfer of critically ill patients.”

HSJ has reported on several cases in recent years of concerns being raised about deaths linked to poor transfers between hospitals, and in 2017 NHS England issued a letter to all trusts urging them to accept transfers of patients needing emergency neurosurgery.

An interim report published in July 2017 found that the patient died from a serious condition that carries a high mortality rate but decided “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”.

The report does not name the man or the NHS providers involved. 

It split its work into two strands: the first on the death of the patient and the second dealing with wider systemic issues.

In the latter, published today, HSIB has called for the Department of Health and Social Care, as well as chief executives of England’s ambulance services, to make changes to fill gaps in national guidance.

Its findings include:

• There was no national guidance to help doctors during emergency transfers of the most critically ill patients between units;
• There are no consistent guidelines for both emergency and planned transfers of critically ill patients;
• There is variation in governance and oversight of the different networks set up to coordinate patient pathways between providers.

HSIB has recommended that DHSC coordinate with the national arm’s-length bodies to develop national guidance “for the transfer of critically ill adults, both in planned and emergency situations”.

Pre-alerts were originally meant to be a means for paramedics to alert emergency departments their impending arrival to allow hospitals to prepare the ED with specialist equipment or teams. But HSIB found they have become “a more detailed pre-hospital handover” of increasing complexity and “longer and more complicated” acronyms.

Ambulances and acute trusts have different processes for pre-alerts and there is no consistency across the country.

HSIB has, therefore, recommended the Association of Ambulance Chief Executives “work with partners to define best practice standards for the criteria, format, delivery and receipt of ambulance service pre-alerts”.

A Department of Health and Social Care spokesman said: ”We want to ensure the NHS continues to be the safest healthcare system in the world, which is why we set up HSIB to shine a light on areas where safety can be improved.

“We thank HSIB for their thorough investigation of this tragic case and we will work with the NHS to respond to these recommendations and further improve the experiences of millions of patients who receive safe emergency care every year.”