Recurring concern

Insufficient detail in referrals for safe risk assessment and prioritisation

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First reported 25 Jul 2014•Latest report 30 Mar 2026

Definition

What this concern includes

Includes failures in safety-critical referrals or referral documentation where missing or inadequate information impairs risk assessment, understanding of case complexity or prioritisation by the receiving service.

Not included

  • Excludes deficiencies in final investigation reports, clinical records, care plans or other documents that are not referrals.
  • Excludes failures to prioritise or respond to referrals when the referral information itself was sufficient.
  • Excludes generic information-sharing or communication failures not tied to a referral or referral documentation.
Reports
18

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
22

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS Greater Manchester Integrated Care Board4
Department of Health and Social Care2
Leeds Teaching Hospitals NHS Trust2
Calderdale and Huddersfield NHS Foundation Trust1
Churchgate Surgery1
Derby City Council1
Derbyshire County Council1
George Eliot Hospital NHS Trust1
Herefordshire and Worcestershire Health and Care NHS Trust1
Hill Care Group1
Kent and Medway Cancer Alliance1
Mid Yorkshire Teaching NHS Trust1
National Institute for Health and Care Excellence1
NHS England1
NHS Surrey and Sussex Integrated Care Board1

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.

  1. Warwickshire

    AI-generated summary

    Ethan Michael Hanson · 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

    Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.

    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 carry critical GP information into hospital assessment

    Wider context from the report

    “Critical GP information not carried forward into the hospital assessment The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer. ”

    Source location

    Ethan Michael Hanson · Prevention of Future Deaths report
    Page 4 · 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

    Implement and disseminate an EMIS and laminated referral protocol covering paediatric pathways, hospital selection, advance contact, documentation and clinically appropriate ambulance transfer.

    Verbatim wording from the response

    “Following this event, we have implemented a new protocol within our EMIS clinical system and also laminated the protocol and displayed in all clinical rooms. This protocol prompts all clinicians, at the point of referral, to:”

    Source location

    Response from Old Mill Surgery GP
    Page 1 · response
    Published 25 June 2026

    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 Emergency Department and Clinical Assessment Unit staff access to the Integrated Care Record System for reviewing GP records.

    Verbatim wording from the response

    “Following a multidisciplinary meeting held on 29 April 2026, it was agreed that all nursing and medical staff within the Emergency Department and Clinical Assessment Unit would be granted access to the Integrated Care Record System. This enables clinicians to review GP records, including the referring clinician’s working diagnosis and clinical considerations, prior to hospital assessment.”

    Source location

    Response from George Eliot Hospital NHS Trust
    Page 6 · response
    Published 25 June 2026

    Open published response
  2. Derby and Derbyshire

    AI-generated summary

    Emma Irene TURNER · 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

    Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.

    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

    Safeguarding referral forms failing to capture key GP-relevant information

    Wider context from the report

    “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests. The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery. Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way. ”

    Source location

    Emma Irene TURNER · 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

    Use a single safeguarding adults referral form across Derby City and Derbyshire County, available online to public and professional referrers.

    Verbatim wording from the response

    “Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding adults, underpinned by a joint Safeguarding Adults Policy which operates across both the Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas. As part of this partnership approach, a single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. This form is available online for members of the public, all partner agencies and providers, including GP practices, to use when making safeguarding referrals.”

    Source location

    Response from Derby City Council
    Page 1 · response
    Published 3 March 2026

    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

    Co-produce and implement a revised safeguarding adults referral form with partners, streamlining information requirements and reducing duplication and complexity.

    Verbatim wording from the response

    “We recognise the concerns raised that some sections of the current template are less directly relevant to GPs and that this may increase the risk of key clinical or contextual information not being clearly set out and potentially delay the safeguarding team’s response. In recognition of this, Derby City Council and Derbyshire County Council have worked in partnership to collate feedback from partner agencies, including GPs, specifically on the structure, content and usability of the Safeguarding Adults Referral Form.”

    Source location

    Response from Derby City Council
    Page 2 · response
    Published 3 March 2026

    Open published response
  3. Northumberland

    AI-generated summary

    Joan WHITWORTH · 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

    Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.

    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 provide pertinent referral information to speech and language therapy

    Wider context from the report

    “1. Whilst pertinent information was not provided to SALT, I am concerned that at assessment on 21 February 2023 there was no reliance upon the information provided in the referral to SALT which identified a concern for her swallow, coughing, weight loss choking. Instead the assessment was based on the verbal account of a member of care home staff. There was no observation of the deceased eating and there was no inspection of her care records. ”

    Source location

    Joan WHITWORTH · 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

    Implement revised electronic SALT referral form questions, mandatory detail fields, and mandatory Next of Kin or LPA information.

    Verbatim wording from the response

    “Following the death of Ms Whitworth and extensive discussion within the wider SALT team, it is acknowledged that changes could be made to the electronic referral form, to encourage more detailed information from the referrer. These changes, which were referred to during the inquest, are due to come into effect in October 2025.”

    Source location

    Response from Northumbria Healthcare NHS Foundation Trust
    Page 2 · response
    Published 30 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.

    Verbatim wording from the response

    “We trust that these measures are sufficient to satisfy your concerns.”

    Source location

    Response from Hill Care Group
    Page 3 · response
    Published 30 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The referral information did not indicate or corroborate dysphagia, swallowing difficulty, coughing or choking requiring face-to-face assessment.

    Verbatim wording from the response

    “prioritised by the Trust SALT team as ‘low priority’ (according to Northumbria Healthcare Foundation Trust (NHCT) SALT departmental prioritisation criteria) due to the description provided of Ms Whitworth’s eating and drinking difficulties and associated risk level. The referral stated that she did not want to swallow lumpy food and that she spat out food and drinks. These are common, often behavioural, issues associated with advanced dementia and not an indication of Oro-pharyngeal dysphagia. The referral also states that there had been no episodes of choking. In addition, there had been no direct correspondence from care home staff to raise concerns, seek advice or request an urgent appointment.”

    Source location

    Response from Northumbria Healthcare NHS Foundation Trust
    Page 2 · response
    Published 30 July 2025

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing dysphagia guidance and referral thresholds were considered sufficient to determine that face-to-face assessment was not required.

    Verbatim wording from the response

    “The current expectation and guidance on dysphagia assessments within the Trust and/or nationally is set out in the Royal College of Speech and Language Therapists guidance, and all SALT staff have undergone robust dysphagia training, which is a post-graduation qualification.”

    Source location

    Response from Northumbria Healthcare NHS Foundation Trust
    Page 3 · response
    Published 30 July 2025

    Open published response
  4. Manchester North

    AI-generated summary

    Mark Anthony Fernandez · 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

    Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.

    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 provide adequate information about care needs in referrals to specialist services

    Wider context from the report

    “1. The referral to the specialist service did not provide adequate information as to his level of care needs to help assist the service conduct an appropriate examination. ”

    Source location

    Mark Anthony Fernandez · 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

    Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.

    Verbatim wording from the response

    “Review of the Learning and Disabilities and Autism policy and Enhanced Patient Observation (“EPO”) policy”

    Source location

    Response from Northern Care Alliance NHS Foundation Trust
    Page 2 · response
    Published 26 March 2025

    Open published response
  5. West Sussex, Brighton and Hove

    AI-generated summary

    Ryan Louis Ouslem · 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

    Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

    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 ensure police officers understand mental health issues and referral information requirements

    Wider context from the report

    “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner. An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training. I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police. SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service. I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide. Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask. ”

    Source location

    Ryan Louis Ouslem · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Joint training with SPFT is not considered workable because its cost and logistical requirements are disproportionate at this stage.

    Verbatim wording from the response

    “We have carefully considered whether joint training with SPFT could provide anything additional which could assist officers when referring matters and providing information to them, however we do not believe it is workable step and the cost and logistics of doing so would not be proportionate at this stage.”

    Source location

    Response from Sussex Police 2
    Page 3 · response
    Published 25 September 2024

    Open published response
  6. Manchester South

    AI-generated summary

    Alan William Rowland Smith · 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

    Alan William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.

    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 provide sufficient detail in referrals for risk assessment and prioritisation

    Wider context from the report

    “2. Where such referrals were made it was essential that sufficient detail be provided to ensure that the degree of risk could be accurately assessed and effective prioritisation could take place. ”

    Source location

    Alan William Rowland Smith · 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

    Deliver a Masterclass on timely vascular and District Nursing referrals, including required referral information and examples of good referrals.

    Verbatim wording from the response

    “In light of the findings in this case, a Masterclass learning event will be delivered in September 2024 to include advice and guidance in relation to the circumstances in which to refer and the information required within a referral to ensure timely triage and progression to care under the vascular surgery team as appropriate.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 1 · response
    Published 19 March 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Specialist referrals are expected to contain relevant information and are returned with requirements when insufficient for prompt triage.

    Verbatim wording from the response

    “It is expected that any referral into any specialist service will be complete to include all relative information to enable the team reviewing / triaging the referral to do so in a timely manner. In circumstances where a referral is processed but the team are unable to promptly triage due to insufficient information, the referral is rejected with details of the information or action required in order to progress.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 2 · response
    Published 19 March 2024

    Open published response
  7. Manchester South

    AI-generated summary

    Mark Jones · 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

    Mark Deardon Jones died at home on 13 November 2020 after a catastrophic haemorrhage at the site of surgery for squamous cell carcinoma of the tongue. Concerns included delays in standard referral pathways and the absence of a national protocol for routinely providing photographs and consistent information to support triage of dental referrals.

    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 standard protocol for routine provision of referral photographs to assist triage

    Wider context from the report

    “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months. 2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed. ”

    Source location

    Mark Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inconsistent provision of information in referrals for triage

    Wider context from the report

    “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months. 2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed. ”

    Source location

    Mark Jones · 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

    Reinforce good oral cancer referral practice in future communications to dental professionals and commissioners.

    Verbatim wording from the response

    “In the light of your recommendation, the Chief Dental Officer (CDO) will again reinforce the importance of good referral practice in future communications on oral cancer to the dental profession and commissioners. In addition, she has recommended that the NHS cascades similar communication and guidance to NHS general medical practitioners who account for the vast majority of cases referred to Head and Neck centres.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 February 2022

    Open published response
  8. Manchester South

    AI-generated summary

    Serena Naomi Roberts · 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

    Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.

    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

    Poor documentation in GP referrals to secondary care

    Wider context from the report

    “3. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care. Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care. ”

    Source location

    Serena Naomi Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. West Yorkshire Eastern

    AI-generated summary

    Sharon Jamela Reeve · 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

    Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

    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

    Referral routing failing to provide radiologists’ reports

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 clarify missing referral information before responding

    Wider context from the report

    “(2) Communications between the clinicians at the district general hospital (‘DGH’) and the tertiary neurosurgical unit were suboptimal. The interaction between them on this occasion yielded no benefit and caused valuable time to be lost. Had the communication been effective, it is likely the patient’s condition would have been identified and treatment provided which would probably have saved her life. The pertinent features of the miscommunication were: 1. Routing the referral sought by radiologists via the treating clinicians rather than direct from the radiologists. This led to incomplete information accompanying the electronic referral (specifically no copies of the CT and MRI reports produced by the radiologists). 2. It was not clear what input the clinicians were seeking from the neurosurgeons. No clear questions were posed. 3. The CT and MRI images were sent by the DGH, but via a slow conduit, with the result that the locum registrar dealing with the referral did not see them. 4. The recipient to the referral at the neurosurgery unit did not probe for further information before responding, even though he was informed that the images had been “linked”. The locum registrar did not endeavour to elucidate what questions were being asked in the referral. There appears to be a lack of firm rules for clinicians in neurosurgery as to whether they must review images before responding. 5. It was apparent from the evidence taken at the Inquest that the two consultant radiologists at the DGH would have been aided by a discussion with a neuroradiologist at the tertiary centre. Instead of puzzling over whether the abnormality should be attributed to a clot or a bleed on the brain, this may have helped identify a diagnosis of hydrocephalus – as was done by the two consultant neurosurgeons who gave evidence at the Inquest in respect of their review of the images. ”

    Source location

    Sharon Jamela Reeve · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Norfolk

    AI-generated summary

    Carol Anne JENNINGS · 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

    Carol Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.

    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 act on tissue viability referrals when referral information is incomplete

    Wider context from the report

    “1. Mrs Jennings was referred to the Tissue Viability Nurse by way of a message being left on a telephone answering machine due to her legs being “red” and “wet” on 12 January 2019. As there was no mention of an “open wound” in the telephone message, no action was taken by the Nurse and the referral was not chased up by the ward. A second referral was made on 21 January 2019 by a different doctor. In evidence the Nurse reported as having too many referrals and not having time to deal with them all. At the resumed inquest evidence was heard that referral by electronic means is being considered which would assist in ensuring consistent and relevant information being provided and an audit trail of referrals and further investigation/patients seen. This is a relatively straightforward system to implement but there is no timescale in place for it to be implemented. ”

    Source location

    Carol Anne JENNINGS · 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

    Implement a mandatory electronic TVN referral form, replacing telephone and answering-machine referrals and requiring accurate patient information.

    Verbatim wording from the response

    “A new electronic referral system will be in place during the first week of next month. As compared with the previous system involving telephone referrals and the practice of answering machine use, which is being discarded, there is now a new e-form which must be used in all cases. The e-form must only be emailed to the TVN nurse as indicated and the referral form’s design means that correct and accurate information about the patient must be included so that the referral and response is efficiently conducted by the TVN. A copy of that form is attached for your information.”

    Source location

    2019-0279-Response-by-Queen-Elizabeth-Hospiatl-Kings-Lynn-NHS-Trust
    Page 1 · response
    Published 18 October 2019

    Open published response
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Data last updated 7 September 2026