Ambulance crew with patient

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

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.


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.

Reference event

The reference event in our investigation involves Kim, a patient who was found unconscious at home. She was taken to hospital by ambulance and then held in the ambulance at the emergency department for 3 hours and 20 minutes.

During the hold in the ambulance, her condition did not improve and the emergency department were not able to care for her as it was full. She was taken directly to the intensive care unit where she remained for nine days. Kim was then transferred to a specialist centre for further treatment.

The national investigation

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.