During an 8-month period, 538 injured patients were transferred from primary hospitals to a referral hospital for further management of their injuries. Delay at the primary hospital was identified in 20% of all transfers and in 40% of patients transferred for management of head injury or multisystem injury. Delay at the primary hospital resulted in a median time from injury to arrival at the second hospital of 4 h. Defects in clinical management during transport included inexperienced escorts, inadequate airway control, ventilation, fluid resuscitation and stabilization of chest injuries. Nearly half of transfers were inappropriate because of the relatively minor nature of the injuries. Most of these had solitary musculoskeletal injuries to the extremities. These patients reflect the marked deficiency of specialist orthopaedic services in western Sydney during the study. Development of a metropolitan regional system of trauma care in western Sydney requires urgent action towards reducing the frequency of transfer, minimizing delays in transfer and maximizing basic resuscitation of seriously injured patients. Some designation of hospital roles is required and needs to be accompanied by a prehospital triage process. The population also has a right to expect adequate specialty services at suburban hospitals to enable treatment of minor and moderate single system injuries. Future trauma system developments should adequately reflect population growth and technological advances in clinical care.