Harm caused by delays in transferring patients to the right place of care

HSIB would like to thank Kim, who generously gave her time and shared her experience of the events documented in this report. In accordance with her wishes, Kim is referred to by name throughout this report.

HSIB would also like to thank the healthcare staff for their engagement with the investigation, and for their openness and willingness to support improvements in this area of care. Staff from acute Trusts and the ambulance service were very welcoming, open, forthcoming and honest when describing the challenges they faced.

Kim lived with her partner, and they had the assistance of a carer to support them with daily activities. Kim loved dogs and especially loved caring for rescue dogs. Prior to her requiring more intensive healthcare support, she would spend hours walking and playing with her dogs.

Sadly Kim died several months after the investigation started.

The format of this report is reflective of a different way of reporting findings from this investigation. There were three interim reports (also known as interim bulletins) published to highlight patient safety risks and staff wellbeing concerns. These were published at the appropriate stage of the investigation as emergent risks were identified and safety recommendations and safety observations were made. This report does not repeat the full content of each interim report however section 4 does present the findings for each report and a brief update since their publication.

This final investigation report should be read in conjunction with the three interim reports to provide the full context, investigation methodology and national findings. Links to these interim reports can be found in the executive summary and section 4.

This report is intended for healthcare organisations, policy makers and the public to help improve patient safety in relation to enabling patients to be in the right place of care, for the right treatment, by the right health or social care staff. For readers less familiar with this area of healthcare, medical terms are explained within the report.

We welcome feedback on our investigation reports. The best way to share your views and comments is to email us at enquiries@hssib.org.uk or complete our online feedback form.

We aim to provide a response to all correspondence within five working days.

This document, or parts of it, can be copied without specific permission providing that the source is duly acknowledged, the material is reproduced accurately, and it is not used in a derogatory manner or in a misleading context.

Background

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 seeks to examine the systems that are in place to manage the flow of patients through and out of hospitals and considers the interactions between the health and social care systems (the ‘whole system’). Issues relating to patient flow affect ambulance crews’ ability to hand over patient care to ED staff. EDs are routinely at, or exceeding, their maximum capacity and this has an impact on their ability to provide safe care.

The management of patient flow has further impacts across the healthcare system; these include delayed responses to 999 emergency calls and to NHS 111 calls that require an ambulance response, cancellation of elective (planned) surgery, and people staying in hospital longer than they need to.

This report brings together the findings from the investigation’s three interim reports and provides an update since they were published. This report is intended to be read in conjunction with the following publications:

• Interim report 1 – Harm caused by delays in transferring patients to the right place of care. Published June 2022.
• Interim report 2 – Harm caused by delays in transferring patients to the right place of care. Published November 2022.
• Interim report 3 – Harm caused by delays in transferring patients to the right place of care. Published February 2023.

Kim had complex healthcare needs and had weekly kidney dialysis. Kim felt unwell in July 2021 and described this as feeling tired. The following day, their carer was alerted to a problem in the house as the dog was barking. The carer went to Kim’s bedroom which was on the first floor of the house. Kim was found unresponsive on the floor. An ambulance was called at 10:40 hours, with an ambulance crew arriving on scene at 10:48 hours. Due to Kim’s position in the bedroom and her being unconscious, further assistance from other crews was required to help move Kim from the bedroom to the back of the ambulance. The ambulance left Kim’s home at 11:35 hours and informed the destination hospital that they had an unconscious female. They arrived at the hospital at 11:46 hours.

Due to the emergency department (ED) being full, a hospital ED doctor assessed Kim in the back of the ambulance and obtained a blood sample for testing. The ED doctor requested the ambulance crew remain with Kim in the back of the ambulance.

The ambulance crew were concerned for Kim’s wellbeing so one of the crew went into the ED to see if Kim could be transferred from the ambulance, however the ED remained full. An intensive care doctor heard the conversation and agreed to assess Kim in the back of the ambulance. After discussion with their on-call consultant colleague, a decision was made to admit Kim to the intensive care unit direct from the ambulance.

Kim remained on the intensive care unit for 10 days and then was transferred to a specialist hospital for management of her dialysis requirements.

The reference investigation identified issues with both hospital bed occupancy and flow of patients into, through and out of the hospital. This contributed to ambulances queuing outside of the hospital with patients being cared for in the vehicles awaiting ED care. Additionally, there were ambulance crews providing care for patients in a corridor of the ED department.

National investigation consolidated findings from the three interim reports

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. Below 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.

New safety recommendation

The interim reports made safety recommendations which have been published on HSIB’s website along with the responses. The investigation recognises that there has been limited time since the interim reports were published for system wide change to be implemented. The evidence continues to demonstrate that challenges remain in the system, posing a threat to patient safety and staff wellbeing.

In interim report 2 a safety observation was made, following the collection of further evidence this has now been escalated to a safety recommendation.

1.1 Emergency admissions

1.1.1 HSIB investigations evidenced safety concerns relating to delays in handing over patients from ambulances to hospital emergency departments (ED). Several referrals to HSIB further supported this safety concern.

1.1.2 In May 2018, the Care Quality Commission (CQC) reported on the increasing pressures in emergency departments ‘not only from an ageing population but from the increasing number of people living with complex, chronic or multiple conditions, such as diabetes, cancer, heart disease and dementia’. In its report the CQC stated, ‘this rising demand is manifested as pressure on emergency departments that is increasing year on year, further exacerbated by spikes in activity driven by seasonally-related conditions’ (Care Quality Commission, 2018).

1.1.3 The NHS 2021/22 priorities and operational planning guidance: October 2021 – March 2022 (NHS, 2021a) includes a priority for ‘Transforming community and urgent and emergency care to prevent inappropriate attendance at emergency departments (EDs), improve timely admission to hospital for ED patients and reduce length of stay’. Contained within that is the requirement to ‘reduce the number and duration of ambulance to hospital handover delays within the system – keeping ambulances on the road is key to ensuring that patients needing an urgent 999 response are seen within national Ambulance Response standards’.

1.1.4 Healthcare systems have been asked to develop ‘effective integrated operational delivery plans underpinned by the UEC [Urgent and Emergency Care] Recovery 10 Point Action Plan – Implementation Guide (NHS, n.d.). It is an expectation that these plans include ‘robust and effective assurance and escalation processes to rapidly identify and mitigate against bottlenecks and risks from across the system that may add pressure to UEC services’ (NHS, 2021a).

1.2 Supporting safe and effective discharge from hospital for patients described as medically ready for discharge

1.2.1 Published documents and reports have detailed the requirements to support safe and effective discharge from hospital. The Hospital discharge and Community Support Guidance (Department of Health and Social Care, 2022a), sets out the Hospital Discharge Service operating model for all NHS trusts, community interest companies, and private care providers of NHS-commissioned acute, community beds, community health services and social care staff in England.

1.2.2 The ‘discharge to assess’ model (Department of Health and Social Care, 2022) has been implemented since March 2020 with the intention to support more people being discharged to their own home.

1.2.3 The document ‘Managing transfers of care – A High Impact Change Model’ (Local Government Association, 2015) was developed in 2015 and was then refreshed in 2019 with input from a range of organisations, including the Local Government Association, the Association of Directors of Adult Social Services, NHS England and Improvement, the Department of Health and Social Care, the Ministry of Housing, Communities and Local Government and Think Local Act Personal Partnership. It was updated in July 2020 to integrate emerging learning from responding to the COVID-19 pandemic.

1.2.4 The criteria to reside tool (a tool that helps clinicians determine appropriate discharge pathways) expects that every person on a general ward should be reviewed by a doctor twice daily to decide whether they still need care in a hospital or could be discharged to another setting, such as their home or rehabilitation unit. The tool supports clinical teams to have discussions and make decisions about whether a person needs to stay in a hospital bed to receive care. If a person no longer needs the support and services of a hospital, a plan should be made concerning the resources and services required to support a safe and timely discharge.

1.2.5 With the implementation of the documents above, there is an expectation that ways of working will reduce the length of stay for people in hospital care, improve people’s health outcomes following a period of rehabilitation and recovery, and will minimise the need for long-term care at the end of a person’s rehabilitation. Mental health services are not within the scope of these documents.

1.2.6 Other documents supporting the discharge of patients to the right place of care, including those that explain the discharge to assess model, have not been explicitly referred to in this report because the patient safety risk related to the whole system rather than specific actions of Trusts.

1.3 Safety management

1.3.1 Safety management is a term used to describe an organised way of managing safety throughout and across organisations. In many safety critical industries, this is done through a safety management system, which many of those industries are legally required to have in place.

1.3.2 In a formalised safety management system, individuals are accountable for the safety risks that they hold. The safety management system will include plans to mitigate the safety risks to be as low as reasonably practicable (ALARP). There may be various layers of responsibility for managing risks and issues in an organisation, however there should be a single point of accountability at each layer to ensure risks and issues are managed appropriately. An example of how this works in practice can be seen in the ‘duty holder’ framework used in Defence Aviation (Ministry of Defence, 2021).

1.3.3 Any risks that are assessed as unacceptable may be escalated to the highest possible level in the organisation. A decision can then be made by the accountable person as to whether to accept the risk or put a plan in place to mitigate or make as low as reasonably practicable.

1.3.4 Accountable persons are also accountable for safety culture, policy and learning (including through effective safety investigations).

This investigation used the following patient safety incident, referred to as ‘the reference event’, to consider the safety risks of delays in handing over care from the ambulance service to emergency departments (EDs). Specifically, the patient, Kim, was cared for in the back of an ambulance for 163 minutes before being directly admitted to the Intensive Care Unit (ICU), bypassing an ED that could not care for her as it was full. After investigating the reference event, the investigation then went on to consider the broader safety issue of harm caused by delays in transferring patients to the right place of care.

Local context

The hospital where Kim was cared for was one of three hospitals which formed the ‘Trust’. The hospitals were spread over a large geographical area and some staff rotated between hospital sites.

The ED in the reference event comprised of a minor treatment area (mostly walk-in patients that needed urgent treatment) and major treatment area (for life threatening emergencies). At times of high demand, patients were looked after in the corridor surrounding the major treatment area. There were designated trolley spaces and temporary curtains were used to provide privacy.

Details of the event

2.1.1 Kim was 55-years-old at the time of the reference event. She had been in hospital several times due to conditions associated with liver disease. Kim told the investigation that the day before her collapse she had felt generally unwell and tired.

2.1.2 A carer was alerted to something not being right as Kim’s dog was barking on the stairs. They went to investigate and found Kim on her bedroom floor, unconscious and fitting.

2.1.3 The carer immediately made an emergency 999 call, at 10:40 hours. The 999 call-handler entered the provided information into the triage system, which automatically assigned the call as a category 1 (Cat 1) emergency call (most urgent and life threatening).

2.1.4 At 10:41 hours, the dispatcher in the 999 service identified an ambulance crew, who were nearby to Kim’s home and had just finished dealing with another emergency task. They were dispatched to Kim’s home.

2.1.5 The ambulance crew arrived at Kim’s home at 10:46 hours (5 minutes after dispatch). The ambulance crew were made up of a paramedic and an emergency care assistant (ECA). The carer escorted the ambulance crew to Kim’s bedroom where they found her unconscious on the floor.

2.1.6 The ambulance crew described Kim as fitting and that she had blood in her vomit, which was both fresh and dried. They described her as very cold to touch and thought she may have “been there a long time”. They administered oxygen and medication in response to Kim’s condition.

2.1.7 The ambulance crew required assistance in putting Kim on a lightweight stretcher so that she could be moved safely out of the house and onto the ambulance trolley. Two further ambulance crews attended to provide assistance.

2.1.8 The ambulance crew called ahead to the nearest emergency department (ED) and told them that they were enroute with an unconscious patient. They left Kim’s home at 11:35 hours and arrived at the ED at 11:46 hours.

2.1.9 When the ambulance arrived at the hospital, they parked in the ED’s ‘priority bay’ and one of the ambulance crew went into the ED to inform hospital staff that they had arrived. A doctor told the ambulance crew member that the ED was full and that it was not possible to bring Kim in from the ambulance. Additionally, there were several other ambulances queuing with patients waiting to be taken into ED.

2.1.10 The ambulance crew member noticed that one of the resuscitation rooms was not in use and asked if Kim could be moved into it. A doctor explained that there were several patients in the ED who may imminently need to be transferred to the resuscitation room and therefore it would not be appropriate to use it for Kim.

2.1.11 The ambulance crew waited with Kim in the ambulance. They monitored her condition and tried to keep her warm. An ED doctor went to the ambulance to assess Kim and take a blood sample for testing. The doctor assessed Kim as being stable so able to continue being cared for in the ambulance.

2.1.12 The ambulance crew believed that Kim was deteriorating and became seriously concerned for her welfare. They were concerned she might have sustained a hypoxic (low levels of oxygen) brain injury.

2.1.13 One of the ambulance crew re-entered the ED and spoke to the medical team; this was overheard by an intensive care unit (ICU) doctor who was assessing another patient. At approximately 14:00 hours, the ICU doctor rang their consultant to discuss Kim’s condition. They agreed that Kim would be assessed in the ambulance.

2.1.14 The ICU doctor went to the ambulance and assessed Kim. Her assessment confirmed that Kim was unconscious, was still experiencing seizures and needed urgent medical care. At approximately 14:20 hours, Kim was then taken directly to the ICU where she was immediately intubated (tube passed down her airway to keep it open) and was taken for further investigations.

2.1.15 Kim was formally handed over to the hospital at 15:07 hours, 4 hours 27 minutes from the 999 call and 3 hours 21 minutes from the ambulance arriving at the ED.

2.1.16 Kim remained in the ICU for 10 days and was then transferred to a neighbouring hospital for specialist treatment for her underlying medical condition.

2.1.17 Kim was discharged home and continued to receive medical care as an outpatient.

This section describes the investigation’s findings in relation to the reference event. It focusses on the system factors that contributed to Kim, being treated in the back of an ambulance before a direct transfer to the Intensive Care Unit.

Sections 3.1 and 3.2 describe factors directly relating to Kim’s care. Sections 3.3 to 3.6 describe contextual factors that were in place at the time of the reference event that influenced Kim’s care. The following six main situational and contextual factors were identified and analysed:

• Ambulance response and delay in ambulance handover to emergency department (ED).
• Patient flow through the hospital.
• Local plans to ensure patients get to the right place of care.
• Patient safety risk management.
• Impact on staff.
• Other factors affected by reduced patient flow.

3.1 Ambulance response and delay in ambulance handover

On scene

3.1.1 The ambulance crew met the ambulance response time for a category 1 priority ambulance and were with Kim within 8 minutes of the call to 999 being made. The time that the ambulance crew spent caring for Kim at her home before leaving for the nearest ED was 47 minutes. This time was needed to ensure that the ambulance crew had enough support to safely move Kim from the side of her bed and down the stairs into the ambulance. During this time, Kim’s clinical symptoms were responded to by the ambulance crew.

At hospital

3.1.2 National policy stated that ambulance handovers to hospitals should take no more than 15 minutes (NHS, 2021b). A hospital handover occurs when all the criteria are met:

• a clinical handover had been given to a registered clinician who works for, or on behalf, of the hospital
• the patient was physically transferred to a hospital bed/trolley/chair
• the crew were free to leave the department.

3.1.3 Kim arrived at hospital at 11:46 hours and the ambulance crew did not leave the hospital until 15:19 hours (a total of 3 hours 23 minutes). When the ambulance arrived at the ED, there were three other ambulances with patients waiting to go into the ED. Over the time that Kim waited in the ambulance, the number of ambulances queuing for ED increased to six. One patient waited over seven hours to be transferred into the ED.

3.1.4 The ambulance crew that cared for Kim told the investigation that they did not feel sufficiently trained or experienced to deliver ongoing care and treatment to patients in the back of an ambulance. This care included personal care such as toileting, mouth care and preventing pressure sores (NHS, 2020). It also included monitoring clinical signs and managing current or new medical needs.

3.1.5 The hospital had four resuscitation rooms, each with a single bed. Three of these were in use while Kim was waiting in the ambulance. One was being kept free in case a patient in the ED deteriorated, of which there were three potential patients. The Trust had previously received a Prevention of Future Deaths report from the local coroner which said that they should keep a resuscitation bay free were possible so that they could manage a deteriorating patient.

3.1.6 The ambulance crew told the investigation that they could see that one of the resuscitation rooms did not have a patient in there and they described their “frustration and anger” that the empty resuscitation room was not used. The crew described waiting in the ambulance as “really scary”, and that Kim was not getting any better “we thought she was going to die on our truck”.

3.1.7 The ED doctors told the investigation they believed that Kim was more stable than the three patients in the ED who had been identified as potentially needing the resuscitation room. There was an additional consideration that the resuscitation room was to be kept free for a patient with an easily passed infection such as COVID-19. It was unknown at the time whether Kim was infected with COVID-19. Therefore, the ED doctors made the decision not to place Kim in the remaining resuscitation room. They told the investigation that if Kim had deteriorated further in the ambulance, and required resuscitation, she would have been taken into the available resuscitation room.

3.1.8 The intensive care doctor that assessed Kim in the back of the ambulance had called their intensive care unit (ICU) on-call consultant for advice. The consultant told the investigation that as Kim was unconscious, she needed to be in the hospital where she could be monitored with the appropriate equipment and staff. The on-call consultant advised the ICU doctor assessing Kim that she was to be taken directly to the ICU. The on-call consultant said that they had never come across a situation where a patient was assessed by an ICU doctor in an ambulance.

3.2 Patient flow into, through and out of hospital

3.2.1 In line with national guidance from NHS England and NHS Improvement ‘Winter preparedness in the NHS’ (NHS England and NHS Improvement, 2021), the reference site told the investigation they had robust internal processes to escalate operational pressures. This included escalation from the ED to the hospital operational management team and to the Trust executive team.

3.2.2 The ED had a total of 24 beds, which included cubicles, trolleys and resuscitation rooms. Information provided to the investigation by hospital staf showed that on the day Kim arrived by ambulance, the ED started the day with 13 patients who had been in the ED (in beds) overnight. This meant that the ED was already operating at 60% of its capacity at the start of the day. There was no plan to move these patients to another part of the hospital. That day ended with 12 patients remaining in beds waiting to be admitted from ED to another part of the hospital.

3.2.3 Outside the normal operating hours of 08:00-22:00 hours, an consultant told the investigation that the ED was an overflow ward for the rest of the hospital. Where appropriate patients had been ‘handed over’ to other clinical areas (such as medical or surgical specialties) and were managed by the relevant medical team from these wards but continued to be nursed by ED nurses until a specific bed in that area was ready to admit the patient to. This meant that if there were any emergent medical needs, doctors from the specialty wards would have to be called for advice.

3.2.4 The investigation was told by staff that it was not uncommon for the ED to hold 22 patients overnight until beds became available on wards the next day. This meant that the ED was already full at the start of a new day. This could result in either ambulances queuing outside of the ED or, in some cases, the hospital requesting that ambulances divert to another hospital within the Trust or to other hospital ED. Hospital staff said that these diversions had become an increasingly regular occurrence, and whilst they reduce immediate demand at that site, they knew it placed a further burden on the other hospitals in the local area. Staff told the investigation these were difficult decisions and ones which caused tensions at times both within the organisation and external to the organisation.

3.2.5 Data provided by the Trust showed that by the end of the day that Kim was admitted to ICU, 12 patients were waiting in ED to be admitted to a hospital ward. The hospital had approximately 250 beds and of those 60 patients were awaiting discharge to social or community care (approximately 25% of inpatients). The hospital was only able to discharge 3 patients on that day. Hospital staff told the investigation that it was not uncommon to have 70 patients (approximately 30% of inpatient beds) awaiting discharge from the hospital and they reported they had seen as high as 130 patients (approximately 55%) awaiting discharge.

3.2.6 Staff told the investigation that the reason for keeping patients in the ED overnight is because many “medically ft [ready] for discharge patients” were unable to be discharged to social or community care. Staff told the investigation that medically ready for discharge means that patients no longer need hospital care and are waiting to be discharged to another care setting that can better meet their needs. Staff said that this could be their home (with or without support), home with organised care, to a rehabilitation centre or to a care or nursing home.

3.2.7 The hospital faced additional challenges due to COVID-19. These included:

• assigning patients to the right ward for their particular needs (such as those that had tested positive for COVID-19, those who may have been in contact with someone who had COVID-19 or who were tested negative for COVID-19)
• care homes refusing to take patients until 14 days after they tested negative for COVID-19 and had not been in contact with anyone positive since that test.

3.2.8 Staff in the Trust told the investigation that they had recognised the challenges created by reduced patient flow through their hospitals. They had taken several steps to try to manage the challenges that they faced.

They had:

• Assigned ‘patient flow matrons’ in each hospital within the Trust.
• Formed a daily multi-disciplinary meeting, that included representatives from social care, to try to address the issues being faced.
• Developed processes for identifying beds and patient movement through the hospital, whilst ensuring care is maintained by the specialist team caring for the patient.
• Instigated daily calls between the local hospitals (within and outside the Trust), the Ambulance Trust and regional NHS England teams to understand current ED demand and predicted patient inflow in order to put in place emergency ambulance diversions to other hospitals as required.

3.2.9 In conclusion, the challenges around discharging patients to the right place of care, for example home, social or community care, reduced the flow of patients into, through and out of the hospital. The impact of this reduced patient flow created a situation where the ED was operating at full capacity during the day, patients remained in the ED overnight and that ambulances were queuing with patients inside waiting to be transferred into the ED.

3.3 Local plans to ensure patients get to the right place of care

Hospital Ambulance Liaison Officer (HALO)

3.3.1 During an observation visit to the hospital, the investigation saw that the Ambulance Trust had provided a senior paramedic to act as a HALO. The investigation observed that the hospital and Ambulance Trusts had implemented this system to try to improve patient handover times.

3.3.2 The HALO worked with hospital Trust staff at the initial ambulance receiving point to: optimise patient flow; minimise patient harm from delays in handover; and instigate diversion of ambulances to other hospitals when handover times could not be achieved. The HALO told the investigation they had no ability to influence patient flow through the hospital. In addition, they told the investigation that the resultant impact caused by not being able to discharge patients considered “medically fit for discharge” is that patients were still waiting in ambulances for long periods of time or were being cared for in a corridor of the hospital with an ambulance crew.

ED capacity

3.3.3 To try to improve patient handover times between ambulances and the ED, another hospital in the Trust had increased its ED capacity at another hospital by adapting a ward to become a new ED area for patients needing major treatment interventions (mostly those patients arriving by ambulance). This involved repurposing waiting and storage areas to be places to care for patients.

3.3.4 The hospital was having twice daily ED bed management meetings where they explored options to try to move patients out of the ED and into wards. The investigation attended this meeting, and 4 ward beds were identified for patients in ED. However, at that time there were a further 16 patients in the ED needing ward beds, with ED at full capacity and with 6 ambulances queuing with patients inside. There were over 130 patients that day who were not in the right place of care as they were waiting discharge to social or community care (approximately 25% of the hospitals inpatient beds).

Discharge of patients from hospital

3.3.5 The investigation noted the sense of achievement in hospital staff when there was any movement of patients from ED or out of hospitals. However, staff described being overwhelmed by the size of the problem daily. Operational staff were observed looking for creative solutions to the challenges in ED, such as utilising beds in the surgery recovery area, the maternity unit and cardiology unit. The hospital Trust had also funded beds in a local hotel to allow patients waiting for social care to be moved out of the wards to improve patient flow. Staff said that within a short period of time these hotel beds were full, and the discharge challenges continued.

3.3.6 The investigation was told that hospital staff were trying “to be innovative” but “can only do so much”. Their sphere of influence was limited to within the hospital, despite most of the challenges relating to patients being transferred to the right place of care, for example discharging patients to social care.

3.3.7 The hospital Trust patient discharge service told the investigation they were asking the families of patients to take on their temporary care needs in the short term, to help relieve the challenges in discharging patients to the right place of care. They said that they felt uncomfortable doing this, but in some cases, this was the only approach that meant that a patient could be discharged.

Rapid assessment and treatment (RAT) room

3.3.8 In one hospital in the Trust, they had repurposed an old office area into a RAT room. It was staffed by a senior nurse, admitting clerk, a health care assistant and sometimes a HALO. There were two small assessment bays and some desks for administrative work.

3.3.9 As soon as an ambulance arrived at the hospital, an ambulance crew member entered the RAT room to give a verbal handover to the senior nurse. The patient was then brought from the ambulance to the RAT room where they were assessed by a healthcare professional. If there were no beds in the ED, the patient would be returned to the ambulance. If a patient required resuscitation or other immediate medical attention, they were taken from ambulance directly into the ED.

3.3.10 The nurse in the RAT room had immediate access to a doctor if needed. The investigation observed that when an ambulance crew had called into the hospital prior to arrival, a doctor was waiting to see the patient.

3.3.11 The investigation observed this process and saw that the hospital took responsibility for the patient within 15 minutes of an ambulance arriving at the hospital. However, when patients were returned to an ambulance it still required the ambulance crew to manage their care needs and monitor them for deterioration.

3.3.12 The RAT room nurse carried out a regular walk down the queue of the ambulances to check and get an update on patients’ conditions. This could take a significant amount of time, not only to record the patients’ conditions, but to physically walk the queue of ambulances. This meant that they could be away from the RAT room for significant periods of time.

3.3.13 The RAT room nurse told the investigation that “Winter pressures [were] non-existent, [there was] just pressure”.

3.3.14 In conclusion, despite the introduction of initiatives to improve handover and patient flow, including a HALO, repurposing of non-clinical areas, and introducing a RAT process, the investigation observed ambulances were still queuing throughout the day and night (see figures 1 and 2).

Figure 1 Ambulances queuing with patients inside mid-afternoon

Figure 2 Ambulances queuing with patients inside late evening (other ambulances out of sight queuing)

3.4 Patient safety risk management

3.4.1 The hospital Trust had several risks recorded on their risk register relating to ED/ambulance handover delays/extended wait times. The Medical Director and senior operational management team for the hospital echoed concerns of the ED staff that the majority of factors that influence risks are outside the Trust’s control. They said that they “can only mitigate the factors that they have control over”. They said they had regular meetings with the local social care system to highlight these challenges, but that social care was unable to respond to them due to their own challenges and priorities. Despite several attempts, the investigation was unable to meet with the local social care services.

3.4.2 The hospital’s operational management team told the investigation that other patient safety issues were created as a result of patients not discharged to social care in a timely manner. As patients stayed in hospital for longer periods than necessary, they were more likely to contract a hospital acquired infection or have a fall and then need a longer stay in hospital. This meant in some cases, where patients had previously been living independently, they then became less independent and needed social care support when they left hospital.

3.4.3 The Ambulance Trust also told the investigation that they were only able to manage risks in its own area of responsibility. They had identified risks relating to patient handover and had a significant number of incidents relating to them. Due to the volume of these incidents, many were delayed in being investigated or had been grouped together and investigated as a theme. Staff at the Ambulance Trust told the investigation they were “overwhelmed” by the number of incidents and were “struggling to manage them”. Staff told the investigation that delays in handing over patients to emergency care meant that ambulances queued at hospitals, and they were not able to respond to 999 calls in the community.

3.4.4 The Ambulance Trust staff described other patient safety issues related to patients being on ambulance trolleys longer than normal. For example, some patients were more prone to skin breaks or pressure sores requiring additional treatment. Additionally, staff said that it was challenging managing a deteriorating patient in an ambulance that had limited space and equipment and that the ambulance crews were not trained to manage patients who may deteriorate over long periods of time.

3.4.5 In conclusion, the investigation found that there was no overall system oversight of patient safety through the health and social care system in the region. While each individual healthcare organisation (ambulance and hospital) was responsible for the safety of patients in their care, there was not a safety management system in place that crossed organisational boundaries. Staff in both the Ambulance and hospital Trust told the investigation that they hoped that Integrated Care Boards would address the management of ‘whole system’ patient safety risks.

3.5 Impact on patients and staff.

3.5.1 The investigation recognises the significant harm caused to patients and families due to delays in transfer to the right place of care. Staff at the Ambulance and hospital Trusts told the investigation that these included patients waiting for ambulances in the community, patients’ health deteriorating in waiting ambulances outside ED and patients being cared for in a “sub-optimal” care/ward setting. However, the investigation heard strong voices of the impact to staff and their ability to give the best care that they could.

3.5.2 Many of the staff told the investigation about their frustration, anger and sadness that they were unable to give patients the care that they wanted to. They said it was like working in a war zone and that “the Blitz spirit can only last for so long”.

Ambulance staff

3.5.3 Ambulance staff told the investigation that they wait outside hospitals with patients in their vehicles for many hours on a regular basis. They said that they felt this impacted them both professionally and personally.

3.5.4 From a professional perspective, ambulance crews said that they were not trained to deliver personal and ongoing care for patients in an ambulance. They said that their role is to respond to 999 calls, carry out immediate lifesaving actions and transport a patient to hospital as quickly as possible. They told the investigation that they “didn’t have the clinical or nursing skills needed” to monitor and care for patients for long periods of time.

3.5.5 They also said that their experience and exposure to variety and number of patients was being reduced as many hours were taken waiting outside an ED with a single patient in their ambulance. A paramedic told the investigation that before the situation where ambulances regularly queued, they may have seen up to eight patients a shift. Now they might see two patients a shift. In some cases, they said that they have stayed with a patient for a full shift at an ED and then when they came back on shift 12 hours later took over care for the same patient.

3.5.6 From a personal perspective, paramedics told the investigation how hard it was to hear radio transmissions between colleagues asking for help and them not being able to respond because they were queuing outside a hospital. For example, a colleague may need assistance to carry a patient out of a difficult location, or an emergency dispatcher makes a general broadcast asking for an ambulance to respond to a category 1 call, but no ambulances were available. Staff told the investigation that knowing that there were very sick people in the community that were not receiving an ambulance was both “frustrating and frightening”.

3.5.7 The Ambulance Trust told the investigation that this impact on ambulance crews, 999 call handlers, emergency dispatchers and clinical teams in the operations centre was significant. Whilst members of the Trust did have access to wellbeing support programs, the nature of the job and seeing and hearing patients suffer meant that many staff were struggling with their own feelings of helplessness, many requiring time of to recover.

Hospital staff

3.5.8 Hospital staff told the investigation that they were worried about patients in ambulances outside the ED. They said that they fully recognised that a bed in the ED was the most appropriate place for those patients, but they just had no ability to bring the patients in from the ambulances.

3.5.9 Staff spoke about the difficult decisions they had to make on an hour-by-hour basis. They said they had found themselves in a situation where they could only have the “most unwell” patients in the ED and the “less unwell, but still very unwell” were managed firstly in an adapted area of the ED or held on an ambulance.

3.5.10 The investigation observed that making these decisions was challenging for staff, and that none of them felt “comfortable” doing so. Staff told the investigation that the sheer volume of patients on top of making difficult decisions relating to ambulance queues was impacting them personally, many saying that they were tired or fatigued by it. The investigation heard that there were increasing numbers of staff reporting sick due to pressures of work.

3.5.11 Several members of the ED nursing team told the investigation that they did not have the facilities or staff to manage long term patients. One nurse said that previously a patient would not be expected to stay in the ED for longer than “two hours, now some have been here for 48 hours”. This caused distractions from the essential and primary role of being an ED nurse.

3.5.12 Patients’ needs change as they stay longer in the ED. Not only do they need to be managed clinically, their personal needs, such as toileting and nutrition, had to be met. Simple facilities to clean patient’s teeth were not readily available as ED was never intended to be a long stay area. An operational manager for the ED said that they were not staffed, organised nor had the facilities to deliver this level of care.

3.5.13 Staff told the investigation that they were frequently told by external bodies that they were a “poor performing ED”. This poor performance related to not meeting the 4-hour and 12-hour ED standards (NHS, 2021b). In addition, staff in ED felt they were being held responsible for the performance of the entire hospital and health and social care system, yet they had no control over bed utilisation in other parts of the Trust and discharge to social care. Staff said that this negatively affected their morale as they were “working hard and doing everything that they could” to improve the situation but felt that they had no control over the wider system to influence change. They felt that the language of “poor performing” was unhelpful and damaging to morale.

3.5.14 The investigation found that the inability to meet the standards reflected challenges across the wider health and social care system rather than the individual hospital Trust.

3.6 Other factors affected by reduced patient flow

3.6.1 The investigation heard other factors (described below) which could be affected by reduced patient flow through the hospital Trust and that could have a bearing on the number of ambulances queuing.

3.6.2 The Medical Director at the Trust described that to help free up beds in ED, patients were sometimes moved to a ward that was not the right place of care for the patient, for example a patient who needed to be on a general medical ward was moved to a urology ward. They said that this created a situation known locally as “safari rounds”, whereby medical teams have to leave their normal ward and find their patients who had been bedded on another ward. This included some patients who were residing in the ED nursed by ED staff but had been clinically admitted to a ward.

3.6.3 Additionally, many patients needed to be on a specific medical ward but may be bedded in the eye hospital, cardiac unit, maternity unit or children’s hospital because there were no beds available within a specific medical unit. This extended the problem of “safari rounds” where doctors had to leave the main site and sometimes walk ten minutes to another hospital site and then find the patient.

3.6.4 The Trust told the investigation that planned surgery had been cancelled because patients were in a bed on the day surgery ward or surgical recovery area. This was a management decision to try to relieve pressures in the ED. An example to the consequences of elective surgery being cancelled was described to the investigation by a senior member in the Trust. A patient that was previously well enough for elective surgery to remove a cancerous tumour had their elective surgery delayed because there was no capacity in the surgical recovery ward. Due to the delay, they became too unwell to undergo surgery which had a significant impact on their life expectancy and quality of life.

3.6.5 Staff in the ambulance and hospital Trusts told the investigation that when access to GP, Urgent Treatment Centre or Minor Injury Units were not available out of hours, there is an increased demand on the ED.

3.6.6 Staff also told the investigation the lack of access to GPs during working hours for patients in the community can exacerbate the problem of patients being brought to ED. For example, the investigation heard of an elderly patient who developed a skin break and could not access a GP for assessment, nor could they get to a treatment centre. They went on to get an infection, became unwell, and were brought to ED by ambulance. The patient could not return to their home because their needs had changed, and they then required a social care package. The challenges that GPs face is being explored in two other HSIB investigations: Continuity of care: delayed diagnosis in GP practices; and Workforce and patient safety: skill mix and staff integration.

3.6.7 The hospital Trust told the investigation that if they reached a decision to discharge a patient to social care at the weekend, social care may not be able to accept them, the hospital Trust believed that this was due to the organisation of social care services and management at the weekend. The hospital Trust told the investigation that they believed that social care had significant challenges, such as staffing issues, funding and ensuring they had the right number of beds.

3.7 Summary

3.7.1 The investigation found that there is a direct link between patients waiting (medically ft for discharge) in the hospital for discharge to social care and patients being cared for inside ambulances and ED.

3.7.2 Challenges around discharge to the right place of care puts pressure on the entire healthcare system. This can result in potential harm to patients such as:

• not being in the right place of care
• acquiring new conditions (for example skin breaks and pressure sores)
• cancelled elective surgery
• patients contracting new hospital acquired infections or becoming care dependent and no longer able to support themselves after discharge.

3.7.3 Both the Ambulance and hospital Trust were trying to manage patient flow and ambulances queuing the best they could but were only able to make limited improvements in the areas within their sphere of influence. The issues faced were multi-factorial. Even within the healthcare system, the entire patient pathway was not integrated. There was not a single point of patient safety oversight and risk management from when a patient called 999 through to when they were discharged from hospital.

This section sets out the findings from the investigation’s three interim reports and provides an update since they were published. This section is intended to be read in conjunction with the following publications:

• Interim report 1 – Harm caused by delays in transferring patients to the right place of care. Published June 2022.
• Interim report 2 – Harm caused by delays in transferring patients to the right place of care. Published November 2022.
• Interim report 3 – Harm caused by delays in transferring patients to the right place of care. Published February 2023.

Discharge to ‘the right place of care’ is dependent on the social and care needs of people and the support systems either required or already in place. This can be very complex and specific to individual people. This investigation has focused on patient flow into, through and out of the hospital system. Other challenges reported by healthcare leaders included pharmacy provision, doctors’ availability to write discharge notes and patient transport services, where outside the scope of this investigation.

4.1 Interim report 1

4.1.1 Interim report 1 looked at systems that are in place to manage the flow of patients into, through and out of hospitals, and considers the interactions between the health and social care systems (the ‘whole system’).

Findings

• Many ambulance patient handover to emergency department (ED) times were increasing, beyond the national standard of 15 minutes.
• When hospitals are unable to discharge patients to the right place of care it can create a ‘back pressure’ through the system resulting in patient harm. The right place of care can include the most appropriate hospital setting, community care, social care, or care at home with a social care package.
• The patient harm created by the ‘back pressure’ is felt on hospital wards, emergency departments, in queuing ambulances and for patients waiting in the community for an ambulance to respond to them.
• Individual services and departments can only make changes within their own area of responsibility. If there are external factors creating patient safety issues, individual services cannot make system wide changes and have limited ability to influence them.
• The harm to patients includes:

- acquiring new illnesses and increased risks of falls because of extended stays in hospitals

- patients not in the right place of care receiving sub-optimal care, such as extended times in an ambulance or being cared for in a ward not set up to deal with their condition, or in a hospital corridor

- deteriorating health in ambulances

- increased risk of death within 3 months for patients who have experienced extended waits in EDs (Royal College of Emergency Medicine, 2021)

- patients who call 999 and do not get an ambulance within national standard timeframes, who either deteriorate or in the worst of cases die before the ambulance arrives.

• The number of patients medically ready for discharge daily in June 2022 was approximately 12,100 patients. This means that people are in hospital when they no longer need to be there.
• Reduced patient flow through hospitals has a direct impact on ambulances queuing at EDs with patients on board, this therefore reduces the ability for ambulances to respond to new 999 calls.
• There is not a patient flow model which considers the constraints and flow of a patient’s journey from the community, through the healthcare system, into the social care system and in some cases back into the community.

Safety recommendations made

Response to safety recommendations

4.1.2 The Department of Health and Social Care (DHSC) provided a response to the recommendations. HSIB reviewed the response to both recommendations to assess whether it would address the safety risks identified. Whilst reference was made to funding decisions and the formation of integrated care boards implemented prior to publication of the recommendation, it was not specific in terms of how these would address the recommendations and there were not any new additional actions identified. Update since interim report publication

4.1.3. Ambulance data has identified that ambulance response and handover times still do not meet the national standards (AACE, 2023), impacting patient safety.

4.1.4. The number of patients who are medically ready for discharge has increased slightly over a 12-month period. In June 2023 it was at approximately 12,350 patients per day (NHS England, 2023) compared with approximately 12,000 in June 2022 (NHS England, 2022b), with a peak of approximately 14,000 patients per day in January 2023.

4.1.5. The DHSC told the investigation that:

‘Our ambition - as set out in the UEC recovery plan - is to improve A&E wait times to 76% of patients being admitted, transferred, or discharged within four hours by March 2024, with further improvement in 2024-25. The plan also commits to reducing Category 2 response times to 30 minutes on average this year with further improvement towards pre-pandemic levels next year. To increase capacity and reduce waits, the plan will deliver 5,000 more staffed, permanent beds this year compared to 2022-23 plans - backed by £1 billion of dedicated funding, alongside 800 new ambulances including specialty mental health vehicles. We have seen improved performance since winter, with 74% patients seen in all A&Es within 4 hours in April 2023, this compares to 65% in December 2022 - up 9 percentage points, and Category 2 ambulance response times also improving from over an hour to an average time of 32 minutes and 24 seconds in May.

The plan also covers actions on patient flow and discharge, including spending an additional £1.6bn on discharge over the next two years; delivering ‘care transfer hubs’ in every system to coordinate and support timely discharge; new approaches to step down care; and publishing new data.’

4.1.6. HSIB believe the original safety risk and issues identified are still present.

4.2 Interim report 2

4.2.1. Interim report 2 looked at how patient safety is managed across the ambulance, hospital and social care systems. The investigation identified that there were gaps in safety and risk management between services and departments in the ambulance and hospital system and across the boundary between hospitals and social care.

Findings

• The investigation heard that patient safety risk is highest in the community when a patient has called 999 and is waiting for an ambulance.
• The investigation found that each service (for example an ambulance service or a hospital) operate independently and patient safety risks are not shared, balanced or managed across the system.
• There is an ‘air gap’ between hospital and social care where patient safety is not managed in a systemic manner.
• The investigation heard that joint working arrangements between integrated care boards (ICB) and social care partners are based on good will rather than formal structures.
• Other safety critical industries have individuals who are accountable for safety, including where safety crosses organisational boundaries.

Safety observation made

Update since publication of interim report

4.2.2. Since the interim report was published there has not been a system put in place to address the safety gaps identified or identify individuals who are accountable for safety. The DHSC told the investigation that ‘the Health and Care Act 2022 gives new power to [the] CQC [Care Quality Commission] to assess ICS’s.’ However, they stated that these assessments would not be in place until 2024 and therefore the investigation was not able to establish whether the assessments would address safety gaps or individual safety accountability.

4.2.3. The investigation has reviewed the DHSC’s Guidance on the preparation of integrated care strategies (DHSC, 2022b). The DHSC told the investigation that ‘the Health and Care Act 2022 puts a duty on ICBs to improve quality of services’ including ‘the safety of the services’. However, a sample of integrated care board and integrated care system strategy documents were reviewed to gain an understanding of how patient safety accountability is to be considered. The investigation found that patient safety was not mentioned in any of these documents.

4.2.4. HSIB believe the safety risk remains and therefore escalates the safety observation to a safety recommendation to address the patient safety ‘air gap’ between health and social care. The intent of this is to apply a patient safety risk management framework across the individual services in healthcare and between health and social care to ensure robust and clear lines of accountability.

HSIB makes the following safety recommendation

4.3 Interim report 3

4.3.1 Interim report 3 looked at how staff wellbeing can impact patient safety. The investigation worked with a health psychologist and identified that there is a link between staff wellbeing and patient safety.

Findings

• Staff at all levels described the challenges they are facing due to pressures at work. Examples of these can be:

- Emergency (999) call handlers described receiving repeated calls from patients waiting for an ambulance. In some cases, the patient was heard to be deteriorating and staff were unable to respond, other than offering telephone advice.

- Emergency ambulance dispatchers told the investigation that it was common to worry about “How many people are we going to kill today?” due to their frustration and sadness at not being able to send ambulances to patients.

- Emergency department staff described making challenging decisions on which patients in queuing ambulances to take into the emergency department for treatment.

- Ward staff described being unable to discharge patients from hospital to an appropriate place of care.

• These can result in moral injury, incivility, burn out and stress.
• The impact is on both individual and team working, meaning that systems do not function as efficiently as possible resulting in patient safety issues.
• Provision of and accessibility to wellbeing services is variable across the healthcare system, and the time and space to reflect and talk about difficult situations is not always available.
• There is a direct link between staff wellbeing and patient safety, however the NHS People Plan wellbeing strategy is not linked to the NHS England patient safety strategy.

Safety recommendation and safety observation made

Update since publication of interim report

4.3.2 NHS England provided a response to the safety recommendation above. They are working towards integrating staff wellbeing into their Patient Safety Strategy. The full response is available on HSIB’s web page.

4.4 Conclusion

4.4.1 The investigation recognises that there has been limited time since the interim reports were published for system wide change to be implemented. However, the evidence, including media reports, continues to demonstrate that challenges remain in the system, and continues to be a threat to patient safety and staff wellbeing.

Association of Ambulance Chief Executives. (2023) National Ambulance Data – Final [Online]. Available at https://aace.org.uk/wp-content/uploads/2023/04/National-Ambulance-Data-to-March-2023-Final.pdf (Accessed 12 May 2023).

Care Quality Commission. (2018) Under pressure: safely managing increased demand in emergency departments [Online]. Available at https://www.cqc.org.uk/publications/themed-work/under-pressure-safely-managing-increased-demand-emergency-departments?msclkid=434075fcf7e11ec80f9c793473b310a (Accessed 9 May 2022).

Civil Aviation Authority. (2023) Introduction to bowtie [Online]. Available at https:// www.caa.co.uk/safety-initiatives-and-resources/working-with-industry/bowtieabout-bowtie/introduction-to-bowtie/ (Accessed 18 May 2023).

Department of Health and Social Care. (2022a) Hospital discharge and community support guidance [Online]. Available at https://www.gov.uk/ government/publications/hospital-discharge-and-community-support-guidance (Accessed 10 February 2022).

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Appendix – Investigation Approach

The reference event incident was reported to HSIB from the Trust. After completion of the reference event investigation the HSIB’s Chief Investigator authorised a national investigation based on HSIB’s patient safety risk criteria, as described below.

Outcome impact – what was, or is, the impact of the safety issue on people and services across the healthcare system?

Patients have many healthcare needs, some starting from an emergency 999 call for an ambulance, transfer to hospital, assessment in an emergency department (ED), admission to a hospital ward then discharge to the right place of care. If there are delays in any of these points of transfer, it can create pressures in the system, most visibly seen as ambulances queuing at the EDs with patients.

The possible harm to patients can take many forms, including:

• Patients dying because an emergency ambulance could not respond in time.
• Patients health deteriorating in the back of an ambulance queuing outside ED.
• Patients with extended stays in EDs have a reduced life expectancy.
• Patients acquiring another health condition, such as an infection, because they cannot be discharged in a timely matter, to the right place of care.
• Cancelled elective surgery because patients are moved to surgical recovery rooms so that space for new patients can be made on wards.

Systemic risk – how widespread and how common a safety issue is this across the healthcare system?

Delayed transfer of patients to the right place of care is widespread across health and social care in England. It includes increased emergency ambulance response times, ambulances queuing outside hospital ED, long stays in ED for patients, and challenges discharging patients from hospital to the right place of care.

Learning potential – what is the potential for an HSIB investigation to lead to positive changes and improvements to patient safety across the healthcare system?

A national safety investigation can provide insight into persistent safety risks and make recommendations that stimulate change. In addition, HSIB investigations provide an opportunity to share learnings from stakeholders and/or healthcare providers who have made improvements to processes and practices.

Evidence gathering

The investigation was completed between February 2022 and June 2023.

The investigation interviewed staff involved in the reference event and met with additional staff from across the wider organisation.

The investigation visited the hospital Trust involved in the reference event, and observed the systems and processes used in trying to improve patient flow into, through and out of their hospital. The investigation additionally visited the Ambulance Trust and spoke to members of the operational and patient safety teams.

The investigation also engaged with national healthcare bodies in the areas being explored (see below). Further evidence was gathered from national policy and guidance, and research literature.

Analysis of the evidence

The investigation used several analysis models throughout the investigation, including process mapping, Bowtie analysis (Civil Aviation Authority, 2023) and appreciative inquiry (Trajkovski et al, 2013) to explore the wider national picture.

Stakeholder engagement and consultation

The investigation engaged with stakeholders (see table A1) to gather evidence during the course of the investigation. This also enabled checking for factual accuracy and overall sense-checking. The stakeholders contributed to the development of the safety recommendation and safety observation based on the evidence gathered.