HSIB final report: Harm caused by delays in transferring patients to the right place of care (24 August 2023)

Summary

Delays in the handover of patient care from ambulance crews to emergency departments (EDs) are causing harm to patients. A patient’s health may deteriorate while they are waiting to be seen by ED staff, or they may be harmed because they are not able to access timely and appropriate treatment.

This national investigation sought to examine the systems that are in place to manage the flow of patients through and out of hospitals and consider the interactions between the health and social care systems (the ‘whole system’). This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. You can view the interim reports on the hub:

• Interim report 1 (16 June 2022)
• Interim report 2 (3 November 2022)
• Interim report 3 (27 February 2023)

Content

The investigation provided further evidence of well recognised issues that contribute to patient harm. These were documented in three interim reports published on HSIB’s website. This is a summary of the findings from these reports:

• The movement of patients into, through and out of hospitals has a direct impact on ambulances queuing at emergency departments and creates patient safety risks and issues throughout the healthcare system (see interim report 1).
• Patient safety is managed differently across the healthcare system and does not consider the ‘air gap’ (see interim report 2) between health and social care.
• There is not a patient safety accountability framework which identifies individuals accountable and responsible for patient safety (see interim report 2).
• Poor staff wellbeing due to stress, moral injury, incivility and burnout (see interim report 3).

Additional national investigation findings

The reference investigation highlighted several challenges that reflect those found across other acute trusts in England. These national challenges include:

• Acute trusts not being able to accept new patients because their hospital is full despite a significant number of patients being medically fit for discharge. This means patients in hospital who no longer need to be there but are unable to be safely discharged to the right place of care.
• Ambulance crews caring for patients in the back of their ambulances for over 12 hours.
• When hospitals are unable to accept new patients, this has a direct impact on flow on other hospitals who will see these patients in addition to their own.
• Planned procedures may be delayed and/or cancelled due to the number of emergency procedures.
• Previous initiatives to improve patient flow have focussed on performance targets in EDs, such as the 4-hour standard, rather than changes to the whole system to facilitate patient flow.
• A key contributor to the problems with patient flow into, through and out of hospitals is not being able to discharge patients who no longer require hospital care.
• Seven-day a week services are expected to include daily reviews however this is not happening across all healthcare providers.
• The criteria to reside tool (a tool that helps clinicians determine appropriate discharge pathways) expects that patients on general wards should be reviewed twice daily to determine suitability for discharge (or need for care in hospital). This has not been consistently implemented across healthcare settings in England.

Safety recommendations

Department of Health and Social Care (DHSC)

• HSIB recommends that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care.
• HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of patients in and out of hospital and implement any changes as necessary.
• In interim report 2 a safety observation was made, following the collection of further evidence this has now been escalated to a safety recommendation: HSIB recommends that the Department of Health and Social Care develops and implements a patient safety accountability framework that spans the health and social care system. This is to help address the lack of accountability relating to patient safety risks spanning health and social care.

NHS England

• HSIB recommends that NHS England includes staff health and wellbeing as a critical component of patient safety in the NHS Patient Safety Strategy.

Safety observations

HSIB has made two safety observations to date as a result of this ongoing investigation. 

1. It may be beneficial for there to be a whole-system patient safety accountability and responsibility framework that spans health and social care.
2. It may be beneficial for NHS organisations to provide time and safe spaces for staff to engage in reflective practice and talk about the emotional impact of their work, with support from people with expertise in staff wellbeing.