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
Individual concerns: 22
Date range: 2014–2026
Stated actions: 22

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 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.

19 Jun2019
West Sussex
Concerns raised1
1. Failure to provide complete information about patient history and deterioration to the GP
This report raised 13 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 1
1. Action
  Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
  Stated by Shaw Healthcare LimitedStated completed
AI-generated summary

James William Francis · 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

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

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 complete information about patient history and deterioration to the GP
Wider context from the report
“I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition ”
Source location
James William Francis · Prevention of Future Deaths report
Page 3 · 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 the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.

Verbatim wording from the response
“I also refer to the attached “Request for attendance of GP” policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service and also the importance of clear communications.”

Source location
2019-0202-Response-by-Shaw-Healthcare
Page 3 · response
Published 23 August 2019
Open published response
24 May2019
South Yorkshire (Western)
Concerns raised1
1. Failure of the CAMHS GP referral form process to capture sufficient information for timely assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Maintain updated referral guidance for use with CAMHS referrals.
  Stated by Sheffield Children'S NHS Foundation TrustStated completed
2. Action
  Review and amend the CAMHS referral form using General Practitioner and service-user feedback.
  Stated by Sheffield Children'S NHS Foundation TrustStated in progress
3. Action
  Update referral guidance to support the revised CAMHS referral form.
  Stated by Sheffield Children'S NHS Foundation TrustStated in progress
1. Action
  Distribute the revised CAMHS referral form and supporting guidance to all General Practitioners by 12 July 2019.
  Stated by Sheffield Children'S NHS Foundation TrustStated planned
AI-generated summary

Noah Lomax · 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

Noah Lomax, aged 15, died on 1 August 2018 after jumping from Conisbrough Viaduct, having previously expressed suicidal intentions and made plans to take his own life. His GP referral to CAMHS was closed because it contained insufficient information for a risk assessment, and his family were not notified. The principal concern was that the referral form and process could result in inadequate information being provided and delays in 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 of the CAMHS GP referral form process to capture sufficient information for timely assessment
Wider context from the report
“1. As I made clear during the Inquest I was concerned about the adequacy of the CAMHS, GP referral form. ████████, Noah’s GP, was inexperienced she had not completed a CAMHS referral form before. She accepted she had not provided sufficient detail in the form. This resulted in CAMHS being unable to assess Noah’s risk and declining Noah’s referral. This in turn meant that Noah did not receive an appointment with CAMHS before his death. The Trust’s investigation report stated that the evidence “suggests that the current referral form does not capture the information required to process referrals without delay.” ████████, CAMHS Clinical Lead, said that there had not been any other problems with the form with GP’s not completing them sufficiently. I am not sure how ████████ is able to be so confident about this. I was told that redesigning the form had been considered by the Trust but was told that this was not the answer. Instead, further training has been provided to GPs within the area. Guidance is attached to the form to assist GPs in completing the form. Having carefully considered the evidence I am not satisfied that steps have been put in place to ameliorate the risk identified. Given the realities of the pressures on a GP’s day expecting a GP to use their 10 minute appointment to extract sufficient information for the referral and then at some point complete a referral form, with which they may be unfamiliar, creates the risk that relevant information may not be provided. I would invite the Trust to reconsider whether the form could be improved to reduce the risk of inadequate or insufficient information being provided which may result in a delay in care. ”
Source location
Noah Lomax · 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
Maintain updated referral guidance for use with CAMHS referrals.

Verbatim wording from the response
“During the inquest it was confirmed that the referral guidelines were being updated with input from a General Practitioner. This has now been completed and the guidance is now in place and being used. The current form will continue to be used alongside the new guidance in mitigation until the actions outlined below have been completed.”

Source location
2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
Page 1 · response
Published 14 August 2019
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
Review and amend the CAMHS referral form using General Practitioner and service-user feedback.

Verbatim wording from the response
“The CAMHS team have commenced a review of the referral form, and a draft form was sent to the Clinical Director for Mental Health commissioning the Sheffield Clinical Commissioning Group (SCCG), for comments. This draft was reviewed by SCCG’s Clinical Reference Group, which”

Source location
2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
Page 1 · response
Published 14 August 2019
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
Update referral guidance to support the revised CAMHS referral form.

Verbatim wording from the response
“consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.”

Source location
2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
Page 2 · response
Published 14 August 2019
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
Distribute the revised CAMHS referral form and supporting guidance to all General Practitioners by 12 July 2019.

Verbatim wording from the response
“consists of a number of General Practitioners and 2 service users. Comments from this group have been collated and are to inform necessary amendments to the referral form. Subsequently the current guidance will be updated to support the new referral form and this will then be distributed to all General Practitioners.”

Source location
2019-0186-Response-by-Sheffields-Childrens-NHS-Trust
Page 2 · response
Published 14 August 2019
Open published response
21 Mar2018
Somerset
Concerns raised1
1. Failure to clearly communicate when psychiatric assessment is believed necessary in referrals
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.

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

Edward Arthur Lundy · 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

Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

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 clearly communicate when psychiatric assessment is believed necessary in referrals
Wider context from the report
“1. Edward Lundy had contact with many professionals in a short period of time and that affected the continuity of his care. Proposed action to set up joint services review with provider organisations involved with an oversight report to be produced. 2. That upon Edward Lundy's discharge into the care of his family, there should have been independent consultation with the family and this should have been documented with the risks being explicitly discussed. Proposed action to ensure that the Psychiatric Liaison Operational Policy stated as such and to disseminate to all liaison teams via pathway meetings and local business meetings. 3. That the doctor referring Edward to the Lambeth Assessment and Liaison Team should have made it clear that he believed Edward should be seen by a psychiatrist. Proposed action that the Training Lead in the Trust be informed that GP trainees should receive risk management training, focussing on crisis intervention services e.g. when to consider CMHT/Home Treatment Team/Inpatient Admission. There has been no evidence produced as to compliance with the recommended actions. There has been no evidence produced as to the findings of the report and its proposed actions being started nationally so as to inform other Mental Health Trusts. That the family received no information as to the proposed actions having been followed through and any resultant changes in procedure. ”
Source location
Edward Arthur Lundy · Prevention of Future Deaths report
Page 1 · concerns
Open source report
16 Feb2017
Manchester South
Concerns raised1
1. Insufficient detail in GP referral documentation to identify case complexity
This report raised 5 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

Thomas Josef Green · 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

Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD 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
Insufficient detail in GP referral documentation to identify case complexity
Wider context from the report
“4. The Court heard evidence that the referral document completed by the GP was not particularly detailed and therefore the complexity of the case was not apparent and the case was accepted. ”
Source location
Thomas Josef Green · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jan2016
Central and South East Kent
Concerns raised1
1. Failure of the GP referral form to capture important medical conditions or history for endoscopy referrals
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

Alice Ada Phyllis Dickenson · 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

Alice Ada Phyllis Dickenson died after a lesion, which was in fact a gastric varix, was biopsied during an endoscopy and caused gastrointestinal haemorrhage. The report identified concern that important medical history, including haemochromatosis recorded on the patient questionnaire, was not transferred to the endoscopy assessment information available to the endoscopist.

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 of the GP referral form to capture important medical conditions or history for endoscopy referrals
Wider context from the report
“That important past medical history may be omitted when referring the patient to the rapid access scheme for an endoscopy. The GP referral form is limited therefore enabling the omission of important medical conditions or history which would assist the endoscopist. ”
Source location
Alice Ada Phyllis Dickenson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
21 Oct2015
South Yorkshire (Eastern)
Concerns raised3
1. Failure of receiving teams to identify and fill gaps in referral information
2. Failure to ensure identification and transfer of key referral information
3. Lack of understanding of key information required in referrals
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.
Actions described in response 4
1. Action
  Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
  Stated by Mid Yorkshire Teaching NHS TrustStated in progress
2. Action
  Expand the MDT meeting allocation from 8–11am to 8am–12:30pm.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
3. Action
  Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
  Stated by Mid Yorkshire Teaching NHS TrustStated planned
1. Action
  Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  The lack of clinical details did not influence the final diagnosis, treatment or outcome.
  Stated by Leeds Teaching Hospitals NHS TrustDisputes the concern
AI-generated summary

Dorothy Cooper · 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

Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.

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 of receiving teams to identify and fill gaps in referral information
Wider context from the report
“During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this. My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture. Matters of concern in summary are : 1. Inadequate training of junior doctors who complete referral forms. 2. A lack of understanding as to what key information is required in referrals of this nature. 3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team. ”
Source location
Dorothy Cooper · 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 ensure identification and transfer of key referral information
Wider context from the report
“During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this. My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture. Matters of concern in summary are : 1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms. 2. Lack of procedures to proactively obtain information to complete gaps in clinical history ”
Source location
Dorothy Cooper · 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
Lack of understanding of key information required in referrals
Wider context from the report
“During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospitals Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture could have painted more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in team of clear clinical parameters but failed to proactively pursue this. My concern that if there is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture. Matters of concern in summary are : 1. Inadequate training of junior doctors who complete referral forms. 2. A lack of understanding as to what key information is required in referrals of this nature. 3. Procedures for ensuring that all recent radiological evidence in matters of this nature is identified and electronically transmitted to the receiving team. ”
Source location
Dorothy Cooper · 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
Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.

Verbatim wording from the response
“The process of inter-provider transfer of care for patients on cancer pathways in West Yorkshire is being revised, collaboratively at present. Both The Mid Yorkshire Hospitals NHS Trust and The Leeds Teaching Hospitals NHS Trust are centrally involved in that improvement work. The main action to improve handover of cases like Mrs Cooper’s will be to embed the revised processes detailed in the Standard Operating Procedure being drafted subsequent to that review. We expect this will be embedded by the end of February 2016.”

Source location
2015-0412-Response
Page 1 · response
Published 21 October 2015
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
Expand the MDT meeting allocation from 8–11am to 8am–12:30pm.

Verbatim wording from the response
“Recently the MDT time allocation has been expanded from 8-11am to 8-12.30pm. On average 55-60 cases are reviewed. The demand on the service is huge and increasing. The staff in the MDT do their reasonable best to obtain the information they need. The MDT is supported by an MDT Co-ordinator/Data Manager who collates the cases for review and records the outcomes of the decisions. There is an increasing tendency to determine a management plan from a provisional or ‘working’ diagnosis made on the basis of radiological and blood tests but this must be regarded as provisional and ultimately a tissue diagnosis from a biopsy or complete resection of the abnormality is required to confirm the impression, or alternatively the patient is monitored to assess the response to empirical treatment, for example with antibiotics”

Source location
2015-0412-Response2
Page 2 · response
Published 21 October 2015
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
Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.

Verbatim wording from the response
“2. The electronic transfer of imaging and other clinical data to support specialist opinions is well embedded, and appears to have functioned adequately in this case. Further promotion of the systems and processes by which this can be achieved will be distributed through our local Mid Yorkshire MDT’s. (completion by end of January 2016)”

Source location
2015-0412-Response
Page 3 · response
Published 21 October 2015
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
Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.

Verbatim wording from the response
“To reiterate the importance of submitting relevant clinical information, the Hepatobiliary MDT Co-ordinator has re-circulated the pathway document that was updated in October 2014 and highlighted the need for completion of the referral form as fully and accurately as possible.”

Source location
2015-0412-Response2
Page 3 · response
Published 21 October 2015
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 lack of clinical details did not influence the final diagnosis, treatment or outcome.

Verbatim wording from the response
“The MDT has noted that you have raised concerns that they reviewed Mrs Cooper’s case at their MDT meeting without adequate clinical details. They wish to highlight the fact that they did make attempts to obtain the details by way of correspondence with Mid-Yorkshire NHS Trust (Pinderfields General Hospital). The team is clear however that the lack of details did not influence the final diagnosis, treatment or outcome.”

Source location
2015-0412-Response2
Page 2 · response
Published 21 October 2015
Open published response
8 Jan2015
Worcestershire
Concerns raised1
1. Failure to record a suggested timeframe for action on referrals
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
  Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated in progress
2. Action
  Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completed
AI-generated summary

Eve Cullen · 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

Eve Cullen, who had epileptic seizures and a fluctuating peri-ictal confusional state, went missing from her family home on 17 July 2014 and was later found dead in an alleyway on 9 August 2014. The concerns were that a hospital referral was not actioned, two urgent referrals were not treated as urgent, and there was no uniform definition or timeframe for urgent 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
Failure to record a suggested timeframe for action on referrals
Wider context from the report
“(1) The failure to action the referral from the Queen Elizabeth Hospital (2) The failure to treat the 2 referrals on the 14th & 15th July 2014 as urgent (3) The lack of any uniform agreement as to what constitutes an 'urgent' referral I received evidence from ████████ Clinical Lead, for the Redditch & Bromsgrove CMHT who confirmed that there was no evidence on the file that the referral on file had been actioned at all. She confirmed that (as set out in the root cause analysis which has been prepared), there is no service wide definition of what might constitute an urgent referral (nor any agreed definition of such terms as 'very urgent', 'immediate', 'routine') and further when referrals are made no suggested timeframe is recorded. She also told me that once the referral is received it is a matter for the psychiatrist as to when the patient is seen, even though the psychiatrist would not have had any contact with a new patient referred in this way. Although it is impossible to tell whether faster action may have changed the outcome in this case it seems that when 2 mental health professionals ask for an urgent referral but no action is proposed for some 8 days that this amounts to a lost opportunity to intervene and possibly save the life of the patient. I would ask the Trust to consider that terms such as 'very urgent, 'urgent', 'routine' etc. should be defined with a view to there being a service wide understanding of what is expected in terms of timely action upon referrals that are made. ”
Source location
Eve Cullen · 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
Develop a countywide standardised urgent-referral system with performance measures and a policy defining urgent and routine response timescales.

Verbatim wording from the response
“Unfortunately, it has not to date been the case that the same process applies in respect of the other areas in which the Trust provides services in Worcestershire, however we are working with the North CCG’s to address this, as it is our ambition to introduce a standardised system across the County. The Trust is working towards performance measures for all categories of referrals and will incorporate into a policy, which will distinguish between urgent and routine referrals with defined timescales for contact.”

Source location
2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 1 · response
Published 8 January 2015
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
Operate the Redditch and Bromsgrove urgent-referral protocol, including triage within 24 hours and face-to-face assessment within 24 hours where required.

Verbatim wording from the response
“I confirm that since receiving your correspondence the Trust has written to all general practitioners in Redditch & Bromsgrove on 4 February 2015 identifying a protocol for the referral of mental health patients and the timescales in which they can be seen. This clarifies that referrals marked urgent should be triaged within 24 hours. The triage process may involve a discussion with the referrer, a discussion with the individual and/or a face to face assessment.”

Source location
2015-0002-Response-by-Worcestershire-Health-Care-NHS-Trust
Page 1 · response
Published 8 January 2015
Open published response
25 Jul2014
Surrey
Concerns raised1
1. Insufficiently detailed EDS referral information about low sodium and blood results
This report raised 13 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
  Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated completed
2. Action
  Attach copies of all investigations to every patient referral letter.
  Stated by Woodlands SurgeryStated completed
Respondent positions 1
1. Position
  GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.
  Stated by Surrey and Borders Partnership NHS Foundation TrustRedirects responsibility
AI-generated summary

Clare Serena Anke COOPER · 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

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

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Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficiently detailed EDS referral information about low sodium and blood results
Wider context from the report
“6. Insufficiently detailed referral letter to EDS (mentioning ‘low sodium’ but not accompanied with a copy of the blood results) and an opportunity was lost for its significance to be considered ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · 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
Revise the GP referral form to require information supporting assessment and exclusion of organic causes before eating-disorder referral.

Verbatim wording from the response
“We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.”

Source location
2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Page 1 · response
Published 25 July 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
Attach copies of all investigations to every patient referral letter.

Verbatim wording from the response
“99% of referrals from Woodlands Surgery go to Surrey and Sussex Healthcare Trust (SASH). The Trust is linked in to the pathology software so for the vast majority of our referrals the hospital does have access to our patients’ pathology results. However from now on all patient referrals will have copies of all investigations (not just blood tests) attached with them to the referral letter.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 3 · response
Published 25 July 2014
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
GPs are expected to consider and exclude organic causes before referring patients to the Eating Disorders Service.

Verbatim wording from the response
“We have revised our referral form in order to try and improve the quality of information that GPs provide when referring patients. The form asks for more detail from the GP including that they consider and exclude organic causes of weight loss prior to making a referral to the Eating Disorders Service. The form also highlights the need for the GP to provide further details of the nature of the eating problem, results of blood investigations, physical examination and past medical history so that all information is available prior to assessment by the Eating Disorders Service.”

Source location
2014-0345-Response-by-Surrey-Borders-Partnership-NHS
Page 1 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide complete information about patient history and deterioration to the GP

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.1

Concerns raised1

Failure of the CAMHS GP referral form process to capture sufficient information for timely assessment

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.4

Concerns raised1

Failure to clearly communicate when psychiatric assessment is believed necessary in referrals

Concerns raised1

Insufficient detail in GP referral documentation to identify case complexity

Concerns raised1

Failure of the GP referral form to capture important medical conditions or history for endoscopy referrals

Concerns raised3

Failure of receiving teams to identify and fill gaps in referral information

Failure to ensure identification and transfer of key referral information

Lack of understanding of key information required in referrals

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.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to record a suggested timeframe for action on referrals

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

Insufficiently detailed EDS referral information about low sodium and blood results

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 4

Actions described in response 4

Respondent positions 1

Actions described in response 2

Actions described in response 2

Respondent positions 1