Pennine Care NHS Foundation Trust

3. Mrs O complains about the care and treatment she received at the Pennine Care NHS Foundation Trust (the Trust) in March 2022. Mrs O complains the Trust staff did not escort her when she was transferred to another Trust.

4. Mrs O’s husband, Mr O, says the doctors at the other Trust repeatedly had to ask him and his daughter about Mrs O’s care and treatment. He said if Mrs O had an escort, they would have been able to provide the other Trust’s doctors with the necessary clinical information.

5. Mr O says this delayed the care and treatment Mrs O needed. He says Mrs O’s lack of timely treatment may have led to her having another cardiac arrest in the resuscitation unit or at least prolonged her recovery.

6. Mr O says Mrs O became very agitated, anxious and stressed during and after the transfer. He says this could have been better managed if someone from the Trust was with Mrs O when she was transferred. Mr O says this also had an emotional impact on him and his daughter.

7. Mrs O would like an apology and acknowledgement of wrongdoing, as well as service improvements to ensure this does not happen again.

8. Mrs O was admitted onto a ward at the Trust around the middle of March 2022 following a mental health referral from another Trust. The Trust’s ward operates on the site of another Trust (Trust B).

9. Mrs O had voluntarily drunk an excessive and harmful amount of water prior to this admission.

10. Two days after her admission Mrs O required emergency treatment. It was suspected she had a pulmonary embolism (PE - a blockage in a lung artery; PE is a serious condition that requires immediate medical treatment). The Trust needed to transfer Mrs O to Trust B to receive emergency treatment for this.

11. Prior to the transfer Mrs O had a seizure and respiratory arrest (when a person stops breathing or is unable to breathe effectively, which cuts off the oxygen supply to the body and can lead to organ failure).

12. Paramedics with an ambulance from another Trust (Trust C), transferred Mrs O to Trust B. A clinician from the Trust did not escort Mrs O to Trust B.

13. Mrs O’s husband and daughter were with her at the time. When Mrs O arrived at Trust B the clinicians asked Mrs O’s husband and daughter questions they could not answer about Mrs O’s health. We understand Mrs O was very agitated during the transfer.

14. We understand Mrs O had a further cardiac arrest at Trust B.

18. Mrs O initially complained about various aspects of her care. The Trust was open and honest about this period of care. We consider the Trust’s response was a good one. As such, the only outstanding issue was if the Trust should have provided an escort for Mrs O’s transfer. This is therefore the only focus of this investigation.

19. To consider if there was a failing here, we compared what should have happened with what did happen. We have done this, and we consider there was not a failing with this part of the complaint.

20. The records show Mrs O was transferred to Trust B’s emergency department via an ambulance with paramedics and without an escort from the Trust, with her family following her. This was after a medical emergency as detailed above. We can see the Trust called a crash team (resuscitation team) and 999.

21. The records show Trust B contacted the Trust ten minutes after the transfer to ask if it was sending over any staff. The Trust said Mrs O was not detained under the Mental Health Act (MHA) (often known as being sectioned), and there were no current risks. It informed Trust B to let the Trust know if the risks increased and it would send staff over to support.

22. The Trust’s policy covers what should be done in a medical emergency. It says staff should use a crash team and/or call 999. It does not specify patients need to have an escort when transferred in an emergency situation.

23. We therefore consider the Trust correctly followed its own policy.

24. NHS guidance PAR461 is the ‘National Framework for Inter-facility Transfers’. It sets out what should happen for patients that require ambulance transfer between facilities due to an increase in either their medical or nursing care need.

25. PAR461 says it is intended for patients who require ambulance transfer between facilities due to an increase in either their medical or nursing care need.

26. PAR461 says a facility, to which the framework applies, is all healthcare facilities that provide inpatient services.

27. The Trust is a healthcare facility that provides inpatient services as it is an NHS Trust and Mrs O was an inpatient at the time. Mrs O also required an ambulance transfer to another healthcare facility that provides inpatient services, because of an increase to her medical need.

28. Therefore, we consider PAR461 applies here.

29. PAR461 says, in its introduction section, patients who have immediate life-threatening injuries or illnesses should be transferred, where necessary with an appropriate hospital escort. It also says requests must be based on the clinical need of the patient.

30. Therefore, we consider the decision to provide a patient with an appropriate hospital escort is a discretionary one based on if this was necessary, which is based on the clinical needs of the patient.

31. Mrs O was on a mental health ward at the Trust under the care of MHNs. It would have therefore been likely a MHN would have been the escort for Mrs O.

32. Therefore, our MHN adviser is able to provide evidence on the necessity of an escort. They advised no specific guidance covers this and therefore the NMC’s code is relevant here. In particular, section 1.2 which says nurses must deliver the fundamentals of care, and section 13 which says nurses must work within the limits of their own competences.

33. They advised from a MHN perspective, the only reasons an escort would be necessary is if a patient was detained under the MHA, or if there were particular concerns or risks relating to their mental health. Such as certain challenging behaviour or medication needs linked to mental health.

34. The evidence suggests this was not the case here. Mrs O was not detained under the MHA. The records show she was an inpatient at the Trust voluntarily. The records also show the Trust had no concerns about any risks relating to Mrs O’s mental health needs. The situation appears to be, exclusively, a physical health emergency.

35. As this was not a mental health emergency, we consider it was not necessary for a MHN to escort Mrs O. Paramedics are trained to deal with physical health emergencies. Our MHN adviser says the paramedics were best placed in this situation to transfer Mrs O and are equipped to deal with any physical health issues that may occur unlike a MHN.

36. This is consistent with the NMC’s code, and the delivery of the fundamentals of care from nurses and nurses working within the limits of their own competences.

37. Further, the records show the paramedics arrived at approximately 11.45am and Mrs O was transferred at 1.15pm. Mrs O had a respiratory arrest while the paramedics were present before the transfer.

38. We therefore consider the paramedics would have been aware of Mrs O situation and could have relayed this information when they transferred her to Trust B.

39. What information the paramedics provided the receiving Trust (Trust B), or the lack of subsequent handover information the Trust provided, does not come under the scope of this investigation.

40. We appreciate the Trust has acknowledged and apologised for not providing appropriate handover information to Trust B. This does not mean, as previously suggested, an escort was necessary.

41. We consider as it was a physical health emergency a paramedic was appropriate to escort Mrs O and it was not necessary for a MHN to escort her. The handover information would have then been helpful following the transfer, and this is a separate matter to the escort. Ultimately, we consider, the escort was not necessary to ensure the transfer was safe.

42. We note Mrs O feels a MHN would have been able to help her anxiety during the transfer. She recalls another time at the Trust when she was transferred with an escort. On that occasion they were able to help calm her.

43. We consider based on Mrs O’s recall a MHN escort may have been helpful. This does not mean a MHN escort was necessary. The Trust had no concerns about Mrs O’s mental health risks, and as said above the medical emergency was regarding Mrs O’s physical health. Although anxiety is a mental health symptom, paramedics are also able to calm and reassure patients.

44. We therefore consider Mrs O not having an escort for her transfer was in line with PAR461 as the escort was not necessary. Therefore, we consider the lack of escort was not a failing and we do not uphold this complaint.

45. We acknowledge the impact of this on Mrs O. We were sorry to learn of the reasons for her complaint. We recognise the period complained about was a very distressing and difficult time for Mrs O and her family. With this decision we do not intend to dismiss or diminish this in any way.

1. This is our final report. We are not upholding Mrs O’s complaint. We consider there was not a failing when the Trust did not escort Mrs O during a transfer.

2. We appreciate how the events complained about impacted Mrs O and her family namely her husband and daughter. We recognise this was a very stressful event for Mrs O and her family which was made more difficult when the Trust did not escort her during her transfer. We acknowledge the added stress and anxiety this caused Mrs O and her family.