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National guidance required for transfer of critically ill patients, report finds

National guidance required for transfer of critically ill patients, report finds
By Valeria Fiore Reporter
28 January 2019

A lack of national guidance and standard practice regarding ambulance transfers causes variation across the country and could put patients at risk, a new report has said.

The Health and Safety Investigation Branch (HSIB) report, published on 24 January, said the Department of Health and Social Care (DHSC) should develop a national guidance for the transfer of critically ill adults.

The independent body launched the investigation after a 54-year old man, whom HSIB refers to as ‘Richard’, died during an emergency transfer after being diagnosed with acute aortic dissection – which occurs when the inner layer of the aorta tears.

Key findings

HSIB decided to split its investigation in two: the first, published on 24 January, focussed on emergency transfers while a second – to be published in spring 2019 – will look at clinical diagnosis of aortic dissection.

HSIB gathered information from different sources, including interviews with paramedics, 999 call handlers, dispatchers, emergency department consultants, interviews with national organisations and experts on both general and emergency transfers.

The key findings from the first part of the investigation include that there is:

  • A lack of guidance to support clinicians during time-critical transfers of the most severely ill patients
  • Inconsistency in guidelines for the transfer of critically ill patients in both planned and emergency situations
  • Variation regarding the governance of Critical Care Operational Delivery Networks, which coordinate patients’ movements between providers
  • Ambulance pre-alerts (when the ambulance crew phones ahead to prepare the hospital) lack consistent structure and guidance

The HSIB investigation comes after a review by Lord Carter, published last year, outlined great variation across all 10 ambulance trusts when it comes to avoiding taking patients to hospitals.

HSIB chief investigator Keith Conradi said: ‘The findings highlighted that there was a varying approach to both emergency and planned transfers, and during the pre-alert process.

‘We have recommended to the bodies with the most influence that consistent standards are developed to help reduce risk and improve outcomes for any critically ill adult needing to be transferred anywhere in the country.’


HSIB concluded that the two following steps should be taken:

  • The DHSC should lead on the development of national guidance for the transfer of critically ill adults, be they in planned or emergency situations
  • The Association of Ambulance Chief Executives (AACE ) should work with partners to establish the best practice to follow with ambulance pre-alerts processes

A DHSC spokesperson said: ‘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.’

National Ambulance Service Medical Directors group chair Dr Julian Mark said AACE welcomed the HSIB’s recommendations and that they are already working towards standardising the pre-alert process across NHS ambulance services.

He added: ‘The safe transfer of critically ill patients is a key part of the ambulance service’s role and we have been working with our partners in other parts of the healthcare system for some time now to improve what can sometimes be a complex process, with the aim of reducing risk to patients and improving clinical outcomes.’


The investigation studied Richard’s case from the outset. While exercising at the gym around 6pm, Richard felt a sudden chest pain and, after getting home and calling NHS 111, he was assessed at home by paramedics, and taken to A&E.

It was then decided that he should be transferred to a tertiary centre for emergency surgery.

However, on his way to the tertiary centre, Richard suffered a respiratory arrest and although he initially recovered, he later went into cardiac arrest.

He was then transferred to the closest A&E and on arrival, the ambulance crew was asked to take Richard to the tertiary centre urgently for surgery.

After being informed that Richard had been in cardiac arrest for 32 minutes, the tertiary centre told the ambulance crew that ‘surgery would be futile’, prompting the crew to divert back to the nearest A&E.

After further unsuccessful efforts to save him, Richard died at 3.15am.

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