Search the hub

This guidance supports services to provide developmentally appropriate care for 0 to 25-year-olds. It sets out proposed actions for integrated care boards, providers and clinical teams to enable safe and effective transition between services. If adopted by systems, this approach will improve continuity of care, health outcomes and young people’s experience.

Transitions in care are high-risk moments for patient safety; whether from hospital to home, mental health settings to community, or across specialties. In this episode of the Voices for Safety podcast, research experts Dr Natasha Tyler, Dr Richard Keers, and Professor Tom Blakeman dive into why transitions in care can present patient safety challenges and the emotional toll on patients and carers. From medication errors to emotional readiness for discharge, they explore research insights that could reshape the future of safer care transitions.

The Medication Management at Transitions of Care Stewardship Framework (the Framework) describes a stewardship approach to support safe and high-quality medication management at transitions of care. It is designed to be incorporated into existing organisational systems, processes and clinical practice.The Framework includes four elements: Governing committeeMultidisciplinary stewardship teamMedication management activitiesMonitoring, evaluation and reporting

In this joint blog by the Patient Association, Sarah one of their callers and Debs, the helpline advisor who took her call, explore what safe discharge from hospital looks like, and what might help should anyone find themselves in an unsafe situation.

This study in the Journal of Patient Safety aimed to determine the incidence and types of adverse events (AEs) in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. The authors found that AEs were common for patients transitioning from the ED to the inpatient setting. They conclude that further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.

This is the second in a series of reports by the Health Services Safety Investigations Body (HSSIB) on the theme of healthcare provision in prison. The first investigation focused on the delivery of emergency care. This investigation looks at improving patient safety in relation to continuity of care for patients detained in prison. In the context of this investigation, ‘continuity of care’ means maintaining a patient’s healthcare throughout the prison system regardless of their location. The investigation considered the movement of patients between prisons, to and from court, and on release. It also looked at patient attendance at appointments for internal primary care services and secondary care outpatient appointments. Findings of this report include: ‘Did not attend’ (DNA) rates for outpatient appointments for patients in prison during 2024 were high, at 52% and 57% for males and females respectively. This compares to a DNA rate in the general population of 26% for both sexes. Female prison patients are often taken to outpatient appointments by male prison officers or a mix of male and female officers. This can affect the patients’ decision making about whether to go or not, particularly for appointments that are for sensitive female clinics such as obstetrics and gynaecology. The use of telemedicine in prison healthcare has declined since the end of the COVID-19 pandemic and it is used rarely in comparison to face-to-face appointments. Telemedicine has the potential to reduce the burden of prison officer escort duties for outpatient appointments (which costs £48m to £50m per year), increase the number of outpatient appointments available per day to patients in prison, and reduce the number of appointments that patients refuse to go to. Patients in prison may not attend pre-arranged appointments because of a lack of information about the appointment caused by privacy and security issues. For example, they may not be informed about timings, the nature of the appointment, or the health reasons and importance of attending. This means they are not able to make an informed decision about their health and whether they want to attend or not. Patients in prison are more likely to miss outpatient appointments than patients in the community, due to the prison regime and logistics beyond the control of the patient. Prison healthcare departments rely on relationships they have developed and maintained with hospital booking teams in order to arrange appointments that fit in with the prison regime. This is due to a lack of formal arrangements between prisons and their local hospitals. Patients who are released following a court appearance, who had treatment planned, are not routinely given information about upcoming appointments they may have. This means they may unknowingly miss booked appointments, delaying their care and treatment. Details about patients who are being transferred to different areas are not always communicated effectively between prison healthcare teams and hospital booking teams. Often hospital booking teams are not made aware that a patient has been transferred until an appointment is missed, which means treatment is delayed. In this report HSSIB recommends that: HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released from court. This will reduce variation and ensure better continuity of care for patients when being transferred or on their release. HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood of patients refusing to attend healthcare appointments, while balancing appointment availability, thus improving the continuity and equality of care. NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. This aims to reduce the burden on prisons of providing escorts and the likelihood of patients not attending appointments.

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) 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. It may be beneficial for there to be a whole-system patient safety accountability and responsibility framework that spans health and social care. 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.

Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.

Christina Ruse was admitted to the Spire Hospital on 14 December 2021 and underwent a total left hip replacement. Her condition deteriorated and observations were commenced at five minute intervals. Mrs Ruse was reviewed and on further deterioration in her condition it was decided to transfer her to the High Dependency Unit, Norfolk and Norwich University Hospital. On arrival of the ambulance Mrs Ruse was undergoing a further investigatory procedure. On this being completed Mrs Ruse was taken to the Norfolk and Norwich University Hospital, where her condition continued to deteriorate and she died on 15 December 2021. The Coroner raised the following matters of concern in this case: East of England Ambulance Trust (EEAST) were telephoned at 19.30 hours to request an ambulance to transport Mrs Ruse to the High Dependency Unit. This was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average time of 18 minutes. There were no emergency ambulances available to assign to this call due to high call demand. An ambulance did not become available until 20.54 hours and arrived on scene at 20.57 hours, by which time Mrs Ruse had deteriorated further and had been taken back into theatre. EEAST staff did wait (exceeding the period of their shift) and Mrs Ruse was taken to the High Dependency Unit at 22.42 hours. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Barbara Hollis (3 October 2022) Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023)

Barbara Hollis underwent a total left knee replacement operation on 22 February 2022. The surgery was uneventful with no complications, however after her return to the ward Mrs Hollis became restless and confused. Following a review of her deteriorating condition the decision was made to transfer her to the High Dependency Unit at the Norfolk and Norwich University Hospital. Arrangements were made for the transfer and the ambulance service was called at 19.51 and were told that immediate clinical intervention was needed, but the agreed hospital to hospital transfer pathway was not followed. There was a two hour delay in ambulance attendance, during which time Mrs Hollis continued to deteriorate. Mrs Hollis was subsequently taken to the High Dependency Unit at the Norfolk and Norwich University Hospital where her condition continued to deteriorate and she died in the early hours of the 23 February 2022. The Coroner raised the following matters of concern in this case: East of England Ambulance Trust (EEAST) were telephoned at 19.51 hours and the caller said that immediate intervention was needed. The incorrect pathway was then followed and it is understood action has been taken in this respect. The call was coded as a Category 2 response, with the aim of responding within 40 minutes and with the average response time of 18 minutes. At 21.17 hours a second telephone call was made to EEAST. An ambulance was on scene at 21.27 hours. There were no emergency ambulances to respond to the initial 999 call due to high demand on the service. It is accepted that EEAST have taken several steps following the increase in call demand and subsequent delays in responding to patients. However, evidence was heard that it will take up to a year to see if these steps are effective. In the meantime, there is concern that future deaths will occur. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Geoffrey Hoad (13 September 2023) Prevention of Future Deaths report: Christina Ruse (3 October 2022)

 On 3 August 2022, Geoffrey Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function.   Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours.         The medical cause of death was: 1a) Sub Acute Myocardial Infarction 1b)  Coronary Artery Atherosclerosis 2) Hospital Admission for Post Operative lieus. Matters of Concern Spire Norwich Hospital called the ambulance service on 6 August 2022 at 18.16 hours. The call was coded as a Category 3 call, requiring a response within 2 hours. The Spire Hospital were told the response would be 6 hours. The ambulance service was called again at 23.45 hours and the call was again coded as a Category 3 call. The ambulance service was called again on 7 August 2022 at 07.38 hours and the call was now coded as a Category 2 call, requiring a response within 40 minutes and with an average time of 18 minutes. Due to continuing demand on the ambulance service, an ambulance did not become available until 08.16 hours. The ambulance arrived on scene at 08.26 hours. The time between calling the ambulance service and an ambulance arriving was in excess of 14 hours. Evidence was heard as to the very high call demand overnight on 6th August 2022 and with regard to the significant pressure the healthcare system was and remains under. Evidence was also heard as to the steps being taken by EEAST in an attempt to deal with this pressure on the healthcare system. Despite the steps being taken by the EEAST, considerable delays in attending to calls continue. Spire Norwich Hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute Trusts, usually the Norfolk and Norwich University Hospital. Spire Norwich Hospital continues to rely on EEAST to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result. At the inquest Spire Norwich Hospital placed great reliance on now being part of an lnterfacility Transfer Group led by the Norfolk and Norwich University Hospital working with the EEAST to look at a pathway in respect of inter hospital transfers. The evidence of EEAST was that this pathway was not expected to reduce delays in inter hospital transfers. This concern has been raised at previous inquest. This Prevention of Future Deaths report raises similar patient safety concerns about delayed transfers from a Spire Norwich Hospital to Norfolk and Norwich University Hospital NHS Foundation Trust to the two reports below. These three patients covered by these reports all died within a nine-month period. Prevention of Future Deaths report: Barbara Hollis (3 October 2022) Prevention of Future Deaths report: Christina Ruse (3 October 2022)

Recent polling from Healthwatch England shows that a fifth of patients referred by a GP for consultant-led care end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted. The result is that tens of thousands of patients could be on a ‘hidden’ waiting list, meaning that GPs are managing greater clinical risk and a greater number of patients whose conditions are often worsening in primary care, whilst communication between providers and access to diagnostics are often not up to scratch.  This report by the think tank Policy Exchange looks at reforms that could be made to the interface between primary and secondary care in order to improve care and prevent patient harm. It considers how improved flows of information and expertise can: better support growing demand in general practice reduce unwarranted variation in service provision enhance care coordination – particularly for those referred for elective procedures enable opportunities to boost generalist medical skills for a new generation of doctors create opportunities for hospital specialists to deliver a greater proportion of care in primary or community care settings, reducing waiting times and the use of more expensive settings for care.

Improving medication safety during transitions of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. This study in the journal Therapeutic Advances in Drug Safety aimed to characterise the nature and contributory factors of medication-related incidents during transitions of care from secondary to primary care. The authors found several themes for future research that could support the development of interventions, including: commonly observed medication classes older adults increase patient engagements improve shared care agreements for medication monitoring post hospital discharge.

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. The Pennsylvania Patient Safety Reporting System (PA-PSRS) identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020.