19 Jun 2019 James William Francis · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Failure to provide complete information about patient history and deterioration to the GP View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Shaw Healthcare Limited
Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
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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.
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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
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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
Open published response
Concerns raised 1
Failure of the CAMHS GP referral form process to capture sufficient information for timely assessment View source
Linked response
Sheffield Children'S NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Sheffield Children'S NHS Foundation Trust
Maintain updated referral guidance for use with CAMHS referrals.
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Sheffield Children'S NHS Foundation Trust
Review and amend the CAMHS referral form using General Practitioner and service-user feedback.
View source
Sheffield Children'S NHS Foundation Trust
Update referral guidance to support the revised CAMHS referral form.
View source
Sheffield Children'S NHS Foundation Trust
Distribute the revised CAMHS referral form and supporting guidance to all General Practitioners by 12 July 2019.
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Noah Lomax · Prevention of Future Deaths report
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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.
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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
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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
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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
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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
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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
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21 Mar 2018 Edward Arthur Lundy · Prevention of Future Deaths report Somerset
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Concerns raised 1
Failure to clearly communicate when psychiatric assessment is believed necessary in referrals View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
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16 Feb 2017 Thomas Josef Green · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient detail in GP referral documentation to identify case complexity View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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.
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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
Open source report
Concerns raised 1
Failure of the GP referral form to capture important medical conditions or history for endoscopy referrals View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Alice Ada Phyllis Dickenson · Prevention of Future Deaths report
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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.
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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
Open source report
Concerns raised 3
Failure of receiving teams to identify and fill gaps in referral information View source Failure to ensure identification and transfer of key referral information View source Lack of understanding of key information required in referrals View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Leeds Teaching Hospitals NHS Trust Mid Yorkshire Teaching NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Mid Yorkshire Teaching NHS Trust
Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
View source
Leeds Teaching Hospitals NHS Trust
Expand the MDT meeting allocation from 8–11am to 8am–12:30pm.
View source
Mid Yorkshire Teaching NHS Trust
Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
View source
Leeds Teaching Hospitals NHS Trust
Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
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Dorothy Cooper · Prevention of Future Deaths report
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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.
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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
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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
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
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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
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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
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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
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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
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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
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8 Jan 2015 Eve Cullen · Prevention of Future Deaths report Worcestershire
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Concerns raised 1
Failure to record a suggested timeframe for action on referrals View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
Open published response
25 Jul 2014 Clare Serena Anke COOPER · Prevention of Future Deaths report Surrey
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Concerns raised 1
Insufficiently detailed EDS referral information about low sodium and blood results View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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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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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
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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
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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
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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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.