Concerns raised 2
Failure to direct screening referrals to the vascular screening team View source Uncertainty within general practice about the screening programme and referral criteria View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
The Glenfield Surgery University Hospitals of Leicester 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. 7
University Hospitals of Leicester NHS Trust
Operate a system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.
View source
University Hospitals of Leicester NHS Trust
Inform GPs through the monthly newsletter about referral procedures for the Screening Programme.
View source
University Hospitals of Leicester NHS Trust
Deliver rolling Vascular Service awareness sessions for GPs through Protected Learning Time events.
View source
University Hospitals of Leicester NHS Trust
Add AAA patient referral pathways to the PRISM referral-guidance system in collaboration with Primary Care colleagues.
View source
The Glenfield Surgery
Complete and share a significant event analysis on AAA referral and screening learning.
View source
The Glenfield Surgery
Disseminate the significant event analysis to the South Leicestershire locality GP group.
View source
The Glenfield Surgery
Include AAA referral and screening learning in the Leicestershire LMC newsletter.
View source See 4 more actions
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AI-generated summary
Michael John Halfpenny · 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
Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.
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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 Failure to direct screening referrals to the vascular screening team
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · 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 Uncertainty within general practice about the screening programme and referral criteria
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Source location Michael John Halfpenny · Prevention of Future Deaths report
Open source 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 Operate a system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.
Verbatim wording from the response “2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
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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 Inform GPs through the monthly newsletter about referral procedures for the Screening Programme.
Verbatim wording from the response “In addition to the above our Head of GP Services has sent out a new communication to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the Screening Programme.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
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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 Deliver rolling Vascular Service awareness sessions for GPs through Protected Learning Time events.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
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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 Add AAA patient referral pathways to the PRISM referral-guidance system in collaboration with Primary Care colleagues.
Verbatim wording from the response “The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.” Source location 2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Open published response
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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 Complete and share a significant event analysis on AAA referral and screening learning.
Verbatim wording from the response “NC originally brought up this case for discussion in our practice meeting. Obviously following which, I was then able to investigate my involvement in the case. I have reflected on how aortic aneurysm should be investigated and have written with my own concerns about the Radiology Departments dealing of my referral in the hope they will reflect upon this and reach their own lessons on this tragic case. I have discussed the case with my partners and have provided this SEA to be sent with my colleagues report to the Coroner. I will ensure a copy of this and my letter to ████████.” Source location Response from Glenfield Surgery
Open published response
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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 Disseminate the significant event analysis to the South Leicestershire locality GP group.
Verbatim wording from the response “In order to disseminate learning to the wider GP community, I have taken the liberty of including a significant event analysis to our locality group which includes a number of practices that work within the South Leicestershire area.” Source location Response from Glenfield Surgery
Open published response
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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 Include AAA referral and screening learning in the Leicestershire LMC newsletter.
Verbatim wording from the response “Obviously, this tragic case has caused all of us to read up about the screening and ask searching questions as a result of which, I have personally completed an SEA. My partner, ████████, who is Chair of the Leicester Medical Committee has included an article in the LMCs newsletter to disseminate learning to the entire GP community. He has also written a formal report for the Coroner detailing his involvement and including a copy of my letter to yourselves as well as my SEA report.” Source location Response from Glenfield Surgery
Open published response
26 Feb 2016 Mr Richard Parkes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1
Failure to assess the risks of excluding patients who are late for appointments on a case-by-case basis View source
This report raised 1 other concern. 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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AI-generated summary
Mr Richard Parkes · 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
Mr Richard Parkes collapsed and died on 28 December 2015 after developing deep vein thrombosis with associated pulmonary thromboembolism. Concerns included poor record keeping, unavailable records from an August appointment, and the practice policy of not seeing patients more than ten minutes late, including on an occasion when Mr Parkes was not seen because he was late.
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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 Failure to assess the risks of excluding patients who are late for appointments on a case-by-case basis
Wider context from the report “1. There was evidence of poor record keeping at The Black Country Family Practice. Specifically records of the August appointment were not available and there was a policy of not seeing patients who were more than ten minutes outside their appointment time . Evidence emerged during the inquest that the GP who had seen Mr Parkes initially on the 12 October 2015 and arranged a further appointment on the 23 October 2015 and crucially, was aware of his medical history had decided not to see him on the latter date when he was late for his appointment.
2. Continuity of care and knowledge of medical history is extremely important in the management of patient care and this GP Practice may wish to consider reviewing their policy and management of record keeping.
3. In addition they may wish to consider reviewing the systems in place for excluding patients who are more than ten minutes or more late for appointments. There are inherent risks in adopting this policy and each case should be considered on a case by basis based on risk assessment .
” Source location Mr Richard Parkes · Prevention of Future Deaths report
Open source report
23 Jun 2014 JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to provide advance, clear and specific notice of GP surgery closures View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
JOAN DOROTHY RICHARDSON · 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 Dorothy Richardson became seriously unwell with rapid swelling, bruising and discolouration of her arm. After her GP surgery was closed for staff training on 21 November 2013, she was seen the following day, suffered a cardiac arrest in hospital, and died; the cause of death was streptococcal toxic shock syndrome. The concerns were that emergency medical cover and clear arrangements for patients should be available when GP surgeries close for training, and that the delay of almost 24 hours contributed to the outcome.
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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 Failure to provide advance, clear and specific notice of GP surgery closures
Wider context from the report “(2) This should be advertised well in advance by notices in the waiting area and in the entrances to the surgery with clear and specific instructions so that patients can seek emergency treatment elsewhere.
” Source location JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report
Open source 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 Send a joint letter to Leeds practices reminding them of obligations for safe cover and clear urgent-care communications during training closures.
Verbatim wording from the response “I have discussed the recommendations of your report with my colleagues, the Medical Directors of Leeds South & East CCG and Leeds North CCG, and we have agreed the following:” Source location 2014-0276-Response-by-Leeds-West-Clinical-Commissioning-Group
Open published response
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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 Make a statement at a centrally organised TARGET event in each Leeds CCG reiterating obligations and recommendations for safe access during training closures.
Verbatim wording from the response “I have discussed the recommendations of your report with my colleagues, the Medical Directors of Leeds South & East CCG and Leeds North CCG, and we have agreed the following:” Source location 2014-0276-Response-by-Leeds-West-Clinical-Commissioning-Group
Open published response
18 Mar 2014 David Gary Chatburn · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2
Unavailability of direct referral to in-house community-based psychiatrists for new patients View source Restrictions on cross-Clinical Commissioning Group referrals without special approval View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
David Gary Chatburn · 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
David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health 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 Unavailability of direct referral to in-house community-based psychiatrists for new patients
Wider context from the report “3. That the GP was unable to refer the deceased, as a new patient, directly to the in-house community based psychiatrist , thus effectively defeating the object.
” Source location David Gary Chatburn · 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 Restrictions on cross-Clinical Commissioning Group referrals without special approval
Wider context from the report “9. That GPs cannot refer patients outside their Clinical Commissioning Group area without special permission/approval by the same . In order to do so, a ‘special case’ must be argued . This potentially limits patient (and practitioner) accessibility and treatment .
” Source location David Gary Chatburn · Prevention of Future Deaths report
Open source 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 Enable mental health patients to choose any clinically appropriate provider for their first outpatient appointment, subject to stated exemptions.
Verbatim wording from the response “You raise a concern that GPs were unable to refer patients outside their Clinical Commissioning Group area without special permission/approval by the CCG and that this potentially limits patient (and practitioner) accessibility and treatment. I can advise that this is no longer the case. From 1 April 2014 patients with a mental health condition have had the same legal rights as physical health patients at first outpatient appointment to choose the provider that will deliver their care. The GP, or other referring healthcare professional, remains responsible for determining the clinically appropriate treatment to meet patients’ needs.” Source location 2014-0126-Response-by-Department-of-Health
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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 Local mental-health access arrangements, including single-point entry, triage and bureaucracy, are for the relevant CCG and Pennine Care Foundation Trust.
Verbatim wording from the response “Your remaining concerns relate to the current system for accessing mental health services in primary care. I am aware that a number of other inquests in the past have similarly focussed on the issue of a lack of clearly defined pathways for referral by GPs into mental health environments. The way in which these services are accessed is decided locally by the relevant NHS Trust. Thus your concerns surrounding the single point of entry, triage system and the evident bureaucracy are also more appropriately dealt with by the Clinical Commissioning Group (CCG) and Pennine Care Foundation Trust (FT). I am aware that the CCG is preparing its response in conjunction with both ████████ (Medical Director for the Greater Manchester Area Team) and Pennine Care.” Source location 2014-0126-Response-by-Department-of-Health
Open published response
6 Mar 2014 Natasha Raghoo · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Unclear policy for access to GP services View source
This report raised 12 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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AI-generated summary
Natasha Raghoo · 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
Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.
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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 Unclear policy for access to GP services
Wider context from the report “6. The policy of access to GP services was not clear leading to misunderstanding by the Princess Royal as to where to send a report.
” Source location Natasha Raghoo · Prevention of Future Deaths report
Open source report
21 Nov 2013 Peter Galea · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 1
Limitations on GPs making direct referrals for admission to a place of safety View source
This report raised 1 other concern. 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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AI-generated summary
Peter Galea · 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
Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.
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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 Limitations on GPs making direct referrals for admission to a place of safety
Wider context from the report “Mr Galea was not known to mental health services and experienced multiple presentations to a number of professionals and agencies within a 72 hour period and had 3 mental health assessments, all of which placed him at a low risk.
Whilst it is a tragedy that the professionals and agencies did not have more of an opportunity to work with Mr Galea before he took his own life, I was concerned, that: -
1) there appeared to be limited mechanisms available to break the cycle of referrals between agencies without more positive action being taken whereby Mr Galea could be in a safe place whilst a more detailed assessment of his needs could be carried out possibly involving a psychiatrist. The family described the referral between agencies as “ping pong”.
2) there were limitations upon the GP making a direct referral to have Mr Galea admitted to Cherry Knowle Hospital, because to do so Mr Galea would have had to go back to the Mental Health Team , with whom he had had three contacts within a 72 hour period. From the evidence it was clear that the GP had a positive relationship with his patient (for 4 years) and although prospectively acquiescing to the patient’s wishes, in exceptional circumstances, it may be that a GP should be able to achieve an admission to a place of safety, even if only for a limited period of time. I readily acknowledge some of the disadvantages which may come into play by way of admission but in raising it there may also be advantages which would promote a patient’s welfare.
3) I was grateful for the assistance of ████████ Consultant Psychiatrist, but he was not able to offer to me any view about what may have been done differently for Mr Galea to avoid this very tragic outcome. In raising the matter with you, it may be that some solution to enhance patient’s welfare and wellbeing can be found to prevent future deaths.
” Source location Peter Galea · Prevention of Future Deaths report
Open source report
8 Aug 2013 Dimitar SHTYANOV · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 1
Lack of awareness among seasonal agricultural workers of how to access GP services 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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AI-generated summary
Dimitar SHTYANOV · 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
Dimitar SHTYANOV, a Bulgarian seasonal agricultural worker with a history of asthma, became ill in August 2012 and attended hospital twice before arriving in cardiac arrest on 11 August; resuscitation was unsuccessful. The inquest recorded the medical cause of death as bilateral pneumothoraces due to acute asthma. Concerns included seasonal workers’ limited awareness of GP, 999 and 111 services, and uncertainty about whether Dimitar’s medicines from Bulgaria were shown to hospital staff.
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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 Lack of awareness among seasonal agricultural workers of how to access GP services
Wider context from the report “(1) Evidence was presented to the effect that the majority of seasonal agricultural workers do not know how to access General Practitioner Services and indeed are not aware of the service . They often access primary health care at need via the accident and emergency department
” Source location Dimitar SHTYANOV · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.