Clinical Negligence Claims Involving Patient Transfers Between Hospitals

Transferring a patient from one hospital to another is sometimes an essential part of their care. A patient may need specialist treatment that is unavailable locally, transfer to a major trauma centre, access to specialist surgery or intensive care, or movement between hospitals as part of an established regional pathway.

For many patients, these transfers take place safely and appropriately.

However, transferring a patient between hospitals introduces additional clinical risks. Responsibility for care moves between teams and organisations, important information must travel with the patient, and healthcare professionals must decide whether the patient is sufficiently stable to make the journey.

When a patient's condition deteriorates during or following transfer, or when treatment is delayed because of problems within the transfer process, allegations of clinical negligence may arise.

These cases can be complex. An adverse outcome does not necessarily mean that the decision to transfer was inappropriate. Expert witnesses must examine the clinical circumstances at the time, including why transfer was required, the patient's condition, the urgency of treatment, arrangements for the journey and communication between the referring and receiving teams.

Why are patients transferred between hospitals?

Not every hospital can provide every form of specialist treatment. Inter-hospital transfers are therefore a normal part of healthcare, particularly where patients require services concentrated within specialist or regional centres.

A patient presenting to a district general hospital with a serious neurological condition, for example, may require transfer to a specialist neurosurgical unit. A critically unwell patient may need a higher level of intensive care, while somebody with significant trauma may require treatment at a major trauma centre. The decision to transfer often involves balancing competing risks.

Keeping a patient at the original hospital may delay access to necessary specialist treatment. Transferring them may introduce risks associated with transportation and temporary separation from the facilities available within a hospital. Expert witnesses must assess those decisions according to what was reasonably known at the time.

Was the decision to transfer appropriate?

One of the first questions in a clinical negligence claim may be whether transfer was clinically appropriate in the first place. Experts may consider the patient's diagnosis or suspected diagnosis, their physiological condition, the treatment available at the referring hospital and the specialist care available at the receiving centre. The fact that a patient deteriorated following transfer does not establish that the decision itself was negligent.

In some situations, transfer may have been necessary precisely because the patient was seriously unwell. The risk of deterioration during the journey may have needed to be accepted because remaining at the original hospital presented an even greater risk. The expert's role is therefore to consider whether a reasonably competent clinician faced with the same information would have regarded transfer as an appropriate course of action.

Was the patient sufficiently stable for transfer?

Clinical stability is often central to inter-hospital transfer cases. Before transfer, healthcare professionals may need to assess whether immediate problems have been identified and managed sufficiently for the patient to undertake the journey.

What constitutes appropriate stabilisation will vary considerably. A patient requiring routine transfer for specialist assessment presents very different risks from someone requiring urgent movement while critically unwell. In emergency situations, it may not be possible or appropriate to wait until every physiological abnormality has resolved before leaving.

The relevant question is not necessarily whether the patient was completely stable, but whether reasonable steps were taken to manage foreseeable risks before and during transfer. Depending on the patient's condition, this might include securing an airway, establishing appropriate intravenous access, providing oxygen, administering medication or ensuring that necessary monitoring and equipment are available during transportation. An expert witness will assess these decisions within the context of the urgency of the situation.

Delays in arranging transfer

Sometimes the allegation is not that a patient should never have been transferred, but that the transfer should have happened sooner. Delays may occur while awaiting acceptance by a specialist team, locating an appropriate bed, arranging transportation or stabilising the patient before departure.

Determining whether a delay amounts to a breach of duty requires careful analysis. An expert will consider when the need for specialist care became apparent, when referral was made, what communication occurred between hospitals and whether reasonable steps were taken to progress the transfer.

Not every delay is within the control of an individual clinician or organisation. Equally, pressures on healthcare services do not automatically make every delay acceptable. Where earlier transfer could potentially have changed the patient's outcome, causation will also require separate consideration.

Communication between the referring and receiving hospitals

Safe inter-hospital transfer depends heavily on effective communication. The receiving team needs to understand why the patient is being transferred, their current clinical condition, treatment already provided and any significant risks or outstanding investigations.

There should also be clarity that the receiving service has accepted the patient and is prepared for their arrival where appropriate. Problems can arise when information is incomplete, outdated or misunderstood. Important investigation results may not be communicated, changes in the patient's condition may occur after the initial referral, or assumptions may be made about which team will undertake the next stage of treatment.

In a clinical negligence claim, expert witnesses may therefore examine telephone records, referral documentation, transfer forms, clinical notes and electronic communications alongside the main medical records. The question is whether the information necessary for safe continuity of care was communicated appropriately.

What level of monitoring was required during the journey?

Patient care does not stop when the ambulance leaves the hospital. The monitoring required during transfer depends on the patient's clinical condition and the risks associated with the journey.

Some patients may require relatively straightforward observation. Others may require continuous physiological monitoring, oxygen, intravenous treatment, airway support or other interventions. The expertise of the professionals accompanying the patient may also be important.

A critically unwell patient may require an appropriately skilled clinical escort capable of recognising deterioration and responding to foreseeable emergencies during transportation. An expert reviewing the case will consider whether the level of monitoring, staffing and equipment was appropriate for the patient's condition rather than applying the same standard to every transfer.

Deterioration during transfer does not automatically mean negligence

Inter-hospital transfers sometimes involve patients who are already extremely unwell. Unfortunately, deterioration can occur despite appropriate preparation, monitoring and clinical care.

Expert witnesses must therefore avoid reasoning backwards from the outcome. If a patient suffers cardiac arrest, respiratory deterioration or another serious complication during transfer, the expert will consider whether that complication was reasonably foreseeable and whether appropriate precautions had been taken.

They may examine whether deterioration was already apparent before departure, whether the patient was reassessed immediately before transfer and whether the clinical team responded appropriately when their condition changed. The occurrence of an emergency during transport is not, by itself, evidence that the transfer was negligent.

The receiving team's responsibilities

Inter-hospital transfer cases can also raise questions about what happened after the patient arrived. The receiving hospital may need to reassess the patient promptly, review investigations and continue or modify treatment according to their current condition.

Problems may arise if the receiving team is unaware of the patient's arrival, if important information has not accompanied them or if further treatment is delayed after transfer. This means the expert investigation may need to examine the entire pathway rather than focusing exclusively on the referring hospital.

Establishing a detailed chronology can help determine when responsibility passed between teams and where any alleged delay or failure occurred.

Multiple experts may be required

Inter-hospital transfer claims frequently cross professional and specialty boundaries. An emergency medicine expert might assess the initial treatment and decision to refer. A specialist consultant may consider whether transfer to their service was required and how urgently it should have occurred. A nursing expert may assess observations, preparation, monitoring or escalation. Critical care expertise may be required where a seriously unwell patient was transported between intensive care environments.

There may also be separate questions about causation. For example, an expert may conclude that transfer should have occurred several hours earlier. A different specialist may then need to determine whether earlier arrival and treatment would probably have changed the patient's eventual outcome. Each expert should remain within their own professional scope while their evidence contributes to an understanding of the complete patient journey.

The importance of a detailed chronology

Timing is particularly important in transfer cases. A few entries within the medical records may represent a much more complicated sequence involving recognition of deterioration, referral, specialist discussions, acceptance, stabilisation, transport and arrival.

Experts therefore often need to reconstruct events carefully. They may consider when the need for transfer first became apparent, when the specialist service was contacted, when the patient was accepted, when transport was requested, when the patient actually departed and when treatment began at the receiving hospital.

This can help distinguish an unavoidable period required to arrange safe transfer from a potentially significant delay in recognising or progressing the need for specialist care.

How Apex Experts can help in clinical negligence cases

Clinical negligence claims involving inter-hospital transfers can require expertise across several stages of the patient's care. At Apex Experts, our panel includes healthcare professionals across nursing, emergency medicine, critical care, surgery and a wide range of medical and allied health specialties.

We help solicitors identify which disciplines are required and match instructions with experts whose current or relevant clinical experience reflects the issues within the claim. Our experts provide independent opinions through initial screening and letters of advice, CPR Part 35-compliant reports, responses to questions, expert discussions, joint statements and trial attendance.

Where several experts are required, the different aspects of the patient's pathway can be assessed by appropriately qualified professionals while each expert remains independent and firmly within their own area of expertise.

Final thoughts

Transferring patients between hospitals is an essential part of modern healthcare, particularly where specialist treatment is concentrated within regional centres. However, the process requires careful clinical decision-making and effective communication.

When allegations of clinical negligence arise, experts may need to consider whether the decision to transfer was reasonable, whether the patient was appropriately prepared, whether transfer occurred with appropriate urgency and whether suitable monitoring and clinical support were provided during the journey. They may also need to examine communication between hospitals and the care provided immediately following arrival.

Most importantly, these cases should not be judged simply by the fact that a patient deteriorated during or after transfer. Many patients are transferred precisely because they are seriously unwell. Expert evidence helps distinguish an unfortunate deterioration despite reasonable care from circumstances in which avoidable delays, inadequate preparation, poor communication or inappropriate monitoring may have contributed to the patient's harm.