HSIB interim bulletin - Harm caused by delays in transferring patients to the right place of care (3 November 2022)

Summary

This investigation by the Healthcare Safety Investigation Branch (HSIB) 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.

This is the second interim bulletin published as part of this investigation, and 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.

The reference event in this investigation involves a patient who was found unconscious at home and taken to hospital by ambulance. They were then held in the ambulance at the emergency department for 3 hours and 20 minutes and during this time their condition did not improve. The patient was taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.

Content

Safety recommendations

HSIB has made three safety recommendations so far as a result of this ongoing investigation:

1. 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.
2. 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.
3. 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

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.