Blurred rear doors of an ambulance.

Transfer of critically ill adults

HSIB legacy content

HSIB legacy content

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

National investigation

This investigation – the first we launched – looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.

Part two, 'Delayed recognition of acute aortic dissection', was published in January 2020.

Investigation summary

We were notified of a 54-year-old man who experienced chest pain during exercise and was eventually diagnosed with an acute aortic dissection. He died in an ambulance during an emergency transfer to a specialist tertiary care centre. Part one of this investigation deals with the transfer. 

This part of the investigation focused on:

  • the transfer of critically ill patients
  • the governance of the networks that support providers involved in transfers
  • preparation of patients for transfer
  • communications between clinicians in different environments and locations. 

This investigation found: 

  • there was a variance of care during patient transfers due to a lack of national guidance for emergency transfers
  • the pre-alert process (where the ambulance crew phones ahead to prepare the hospital) is inconsistent in terms of length, the volume and order of information and who delivers that information. 

Part two has a focus on the clinical diagnosis of aortic dissection.