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 and part two is due to be published in Spring 2019.

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 will follow and has a focus on the clinical diagnosis of aortic dissection.

Safety recommendations 

We've made safety recommendations to the Department of Health and Social Care and the Association of Ambulance Chief Executives as a result of this investigation. 

We expect that these organisations will respond to their recommendations within 90 days of the publication of the investigation report. Their responses will be published here when they’re available.

Department of Health and Social Care 

Recommendation 2019/025

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.

Association of Ambulance Chief Executives

Recommendation 2019/026

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.

Safety observations

Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.

This investigation makes the following safety observation:

It would be beneficial for formal governance arrangements to be established to oversee the transfers of critically ill patients.

Find out more by reading our report launch news story.