Our new report, published 24 January 2019, shows that a lack of national guidance and standard practice for ambulance transfers could be putting patients at risk. 

The report puts forward key recommendations aimed at making transfers safer for adults that are critically ill. 

This investigation was launched after we were notified of the case of Richard, a 54-year old man, who died during an emergency transfer to a specialist care centre. He had been diagnosed with an acute aortic dissection after experiencing chest pain during exercise earlier that day. Aortic dissection occurs when the innermost layer of the wall of the aorta tears, allowing blood at high pressure to flow in between the layers forcing them apart.

Lack of national guidance

The investigation found that there is variance of care in emergency transfers due to a lack of national guidance. Although guidance is in place for planned transfers, it is complex and not always standardised across networks. 

It also found that 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. 

Safety recommendations

The report sets out two safety recommendations: 

  • The Department for Health and Social Care (DHSC) coordinates 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 Association of Ambulance Chief Executives (AACE) works with partners to define best practice standards for the criteria, format, delivery and receipt of ambulance service pre-alerts.

Responses to the recommendations will be published on our transfer of critically ill adults investigation page when they’re available.

Chief Investigator’s statement

Keith Conradi, Chief Investigator, said: “This investigation covered a complex case that involved a long transfer and multiple trusts. However, it was clear that many of the factors in the case also had wider implications for the healthcare system and that there was more that could be done at a national level. 

“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.”

Investigation split

This investigation was the first that we launched. It has now been split into two parts. This report, part one, focuses on the transfer segment of the investigation. Part two, focusing on the clinical diagnosis of aortic dissection, is due in Spring 2019. 

Read the report

Download and read the Transfer of critically ill adults report.


Dr Kevin Stewart, Medical Director, introduces the report and talks about the patient safety risks identified.