Recurring concern

Unreliable nurse-to-doctor escalation in primary care

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First reported 4 Dec 2013•Latest report 19 Oct 2023

Definition

What this concern includes

Includes failures in primary-care arrangements for recognising, deciding, initiating, communicating or tracking nurse-to-doctor escalation or referral, including absent or unclear triggers, guidance, responsibility and follow-up for patients requiring medical review.

Not included

Excludes specialist, hospital, mental-health or social-care referral pathways where primary-care nurse-to-doctor escalation is not the shared unsafe condition.
Excludes generic staffing, communication, training or documentation deficiencies unless they directly impair nurse-to-doctor escalation in primary care.
Excludes failures in a doctor's assessment or treatment after the escalation or referral has been reliably completed.
Excludes routine referrals that do not concern a need for timely medical assessment by a doctor.

Reports: 3
Individual concerns: 3
Date range: 2013–2023
Stated actions: 5

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS Greater Manchester Integrated Care Board1

Rocky Lane Medical Centre1

St Stephens Gate Medical Practice1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

19 Oct2023
Sefton, St Helens and Knowsley
Concerns raised1
1. Failure to escalate concerning patient presentations to a doctor
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Wayne MILNE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Wayne Milne attended hospital with chest pain on 28 February 2022 but was discharged without required chest-pain assessments and senior review. On 2 March 2022, after reporting further symptoms to his GP practice, he was advised to attend the emergency department, but the nurse did not call 999, escalate to a doctor, or check whether he had obtained urgent care; Wayne was later found deceased at home from haemopericardium due to a dissecting aortic aneurysm. The report identifies concerns about inconsistent procedures for summoning emergency assistance, escalation and follow-up, and awareness of dissecting aortic aneurysm within the practice.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate concerning patient presentations to a doctor
Wider context from the report
“2. The nurse at the practice told the Inquest, the procedure for practice staff calling 999 (not leaving it to the patient) in the event of a patient with chest pain and other life threatening conditions applied only to reception staff and not to nursing staff. This led to inconsistency and in this case an avoidable delay in summoning urgent medical assistance and needs reviewing/all staff working in/working on behalf of the practice need to be aware of the procedure to be followed, consideration must be given as to whether it is appropriate to have different standards for qualified nursing and administrative/non qualified nursing staff. The awareness of Dissecting Aortic Aneurysm and the rapidity at which the condition can become catastrophic/fatal also needs raising within the practice. The nurse within the practice who spoke with Wayne on the date of his death on behalf of the practice , did not escalate to a doctor, did not call 999, she did not inform the NOK of her concerns, she did not call back to see if Wayne had called for an ambulance/attended hospital and she did not alert the hospital of her suspicions i.e. differential diagnoses including; PE, cardiac related problem or aortic aneurysm. The GP to whom this regulation 28 (Prevention of Future death) report is addressed informed the court (in a witness statement) no action had been taken within the practice since these events. ”
Source location
Wayne MILNE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Apr2020
Manchester South
Concerns raised1
1. Lack of a clear nurse-to-doctor escalation process
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Provide Trafford practice nurses with access to formal clinical supervision through the Practice Nurse Development Lead.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
2. Action
  Provide enhanced Medicines Management support to the practice, focused primarily on safety issues.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
AI-generated summary

George Townsend · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

George Townsend, who was receiving long-term antibiotic therapy, developed worsening diarrhoea and was later diagnosed in hospital with Clostridium difficile infection and pneumonia. He died at Trafford General Hospital on 30 August 2019 from multi-organ failure due to bronchopneumonia. The concerns included delayed GP assessment and testing, inadequate escalation from the nurse to a doctor, failure to recognise the risks associated with his health conditions, poor medical record-keeping, and longstanding concerns about GP practice capacity and oversight.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clear nurse-to-doctor escalation process
Wider context from the report
“1. The inquest heard that Mr Townsend should have seen a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GPs to see patients. In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the practice. ”
Source location
George Townsend · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Trafford practice nurses with access to formal clinical supervision through the Practice Nurse Development Lead.

Verbatim wording from the response
“To offer some wider assurance around escalation and nursing support, the CCG confirms that all Practice Nurses in Trafford are given the opportunity to gain clinical supervision which is a formal systematic and continuous process of professional support and learning for practicing nurses. This is provided by the CCG Practice Nurse Development Lead, who is also a qualified practice nurse herself. This is a self-referral process which relies on the Practice Nurses contacting the Practice Nurse Development Lead directly and arranging a clinical supervision appointment. In the case of an Advanced Nurse Practitioner the expectation is that they would seek clinical supervision from any of the GP’s in their practices.”

Source location
2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
Page 4 · response
Published 22 October 2020
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide enhanced Medicines Management support to the practice, focused primarily on safety issues.

Verbatim wording from the response
“Between August and the 30th September 2019 Dr ████████ had the right to appeal the CQC’s decision to terminate his registration and duly started to do so, and whilst the CCG could not appoint a caretaker nor formally intervene in the day to day running of the practice (this remained the responsibility of Dr ████████) the CCG did provide the usual general support which included engagement with the ANP directly on a number of occasions for assurance around competence and that she would seek clinical supervision from the GP’s in the practice if she felt unsure about any issues. The CCG also provided additional Medicines Management support from the end of July to mid-September, primarily focusing on safety issues. This was over and above what a practice this size would normally receive (3 days a week as opposed to one).”

Source location
2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
Page 6 · response
Published 22 October 2020
Open published response
4 Dec2013
Norfolk
Concerns raised1
1. Lack of guidelines or triggers for practice nurse referral to a doctor
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Arrange for a paediatrician to deliver a module on referral for a sick child.
  Stated by St Stephens Gate Medical PracticeStated planned
2. Action
  Arrange for all clinicians to complete the Department of Health’s “Spotting the Sick Child” e-learning tool.
  Stated by St Stephens Gate Medical PracticeStated planned
3. Action
  Provide laminated copies of the NICE Traffic Light guidance in all nurses’ consulting rooms.
  Stated by St Stephens Gate Medical PracticeStated planned
AI-generated summary

YUKI NORMAN-KNIGHT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Yuki was a very young child who had a persistent cough and was seen at a walk-in centre and twice by practice nurses, receiving diagnoses of chest infection and courses of antibiotics. She later became unresponsive while with her father and died despite resuscitation efforts. Concerns related to checking her past medical history, guidance for practice nurses to refer children to a doctor, and appointment systems for securing a doctor’s assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidelines or triggers for practice nurse referral to a doctor
Wider context from the report
“(2) On the evidence given to the Inquest there appeared to be no guidelines or triggers for when a practice nurse should refer a patient to be seen by a doctor. I am therefore concerned that the systems at St Stephens Gate Medical Practice for such a referral, especially in the case of a very young child or baby may need to be reviewed. ”
Source location
YUKI NORMAN-KNIGHT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Arrange for a paediatrician to deliver a module on referral for a sick child.

Verbatim wording from the response
“2. St Stephens Gate Medical Practice assures the Coroner that any Nurse Practitioner or Practice Nurse will have the support of a duty doctor at all times. Moreover, the Practice is arranging for a”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 1 · response
Published 23 February 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Arrange for all clinicians to complete the Department of Health’s “Spotting the Sick Child” e-learning tool.

Verbatim wording from the response
“paediatrician to attend here and present a module on ‘Referral for a Sick Child’; and also for all clinicians to undertake: ‘Spotting The Sick Child’, an e-learning tool commissioned by the Department of Health.”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 2 · response
Published 23 February 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide laminated copies of the NICE Traffic Light guidance in all nurses’ consulting rooms.

Verbatim wording from the response
“In recognition of this NICE guidance, in the event of any doubt a nurse would refer to or at the very least discuss a case of concern with a GP. We use the NICE ‘Traffic Light System for Identifying Risk of Serious Illness (new 2013)’, and are arranging for laminated copies of the Traffic Light guidance to be present on desks in all nurses’ consulting rooms.”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 2 · response
Published 23 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to escalate concerning patient presentations to a doctor

Concerns raised1

Lack of a clear nurse-to-doctor escalation process

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Lack of guidelines or triggers for practice nurse referral to a doctor

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Actions described in response 2

Actions described in response 3