An ambulance drives at speed past the houses of parliament in Westminster.

Harm caused by delays in transferring patients to the right place of care


The national investigation

This investigation explores issues around patient handover to emergency care.

Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment.

We’ve published an interim bulletin as part of this investigation, which outlines early investigation findings and recommends a national response to tackle this urgent issue.

Findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety.

Reference event

The reference event in our investigation involves a patient who was found unconscious at home. They were taken to hospital by ambulance and then held in the ambulance at the emergency department for 3 hours and 20 minutes.

During the hold in the ambulance, the patient’s condition did not improve. They were taken directly to the intensive care unit where they remained for nine days. The patient was then transferred to a specialist centre for further treatment.

Investigation summary

The investigation explores:

  • Patient flow through hospitals.
  • How delays in discharging patients from hospitals to social and community care impacts on the ability to move patients from an ambulance into an emergency department and on to the right place of care.