Transfer of critically ill adults

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This investigation – the first we launched – looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.

Part two, 'Delayed recognition of acute aortic dissection', was published in January 2020.

Investigation summary

We were notified of a 54-year-old man who experienced chest pain during exercise and was eventually diagnosed with an acute aortic dissection. He died in an ambulance during an emergency transfer to a specialist tertiary care centre. Part one of this investigation deals with the transfer.

This part of the investigation focused on:

the transfer of critically ill patients
the governance of the networks that support providers involved in transfers
preparation of patients for transfer
communications between clinicians in different environments and locations.

This investigation found:

there was a variance of care during patient transfers due to a lack of national guidance for emergency transfers
the pre-alert process (where the ambulance crew phones ahead to prepare the hospital) is inconsistent in terms of length, the volume and order of information and who delivers that information.

Part two has a focus on the clinical diagnosis of aortic dissection.

Safety recommendations

Department of Health and Social Care

It is recommended that the Department of Health and Social Care should co-ordinate the development of national guidance, with the arm’s length bodies, for the transfer of critically ill adults, both in planned and emergency situations.

The Department of Health and Social Care will take on a coordinating role alongside arms-length bodies to ensure that external stakeholders are appropriately consulted on the content of national guidance. We are currently conducting work to determine the scope of the updated guidance, and will provide HSIB with quarterly progress updates as work progresses to complete the scoping exercise and begin the process of producing updated guidance.

Response received on 23 April 2019.

Association of Ambulance Chief Executives

It is recommended that the Association of Ambulance Chief Executives should work with partners to define best practice standards for the criteria, format, delivery and receipt of ambulance service pre-alerts.

The National Ambulance Medical Directors Group (NASMeD) have considered your report and recognises the importance that pre-alerts from ambulance service to hospitals can play in the delivery of care to patients.

The Ambulance Lead Paramedics Group (ALPG) have been asked by NASMeD to assess current practice across the 10 regional English Ambulance Services and to take forward your recommendation.

As you are aware, variation exists and for a variety of reasons. To better understand the complexities, ALPG will work with the Royal College of Emergency Medicine and from this work, we hope that best practice guidance can be agreed.

NASMeD will look to support this work as necessary and if it is helpful we can update you in due course as to further progress.

Response received on 18 April 2019.

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