First reported 2 Jun 2014•Latest report 25 Jun 2026
Definition
What this concern includes
Includes failures in arrangements for recognising when tertiary specialist referral is needed, defining referral thresholds or routes, initiating and communicating the referral, and ensuring the receiving tertiary service can provide timely specialist advice or accept the referral.
Not included
Excludes routine referrals to non-tertiary specialist services.
Excludes transfers or continuity-of-care arrangements after a tertiary referral has been accepted; those belong to transfer or care-transition concerns.
Excludes failures limited to the clinical quality of tertiary treatment or advice after referral has operated reliably.
Excludes generic communication, staffing or documentation deficiencies unless they directly impair referral to a tertiary specialist service.
Excludes referrals to a named condition-specific pathway when that narrower pathway supplies the more specific supported recurring concern.
Reports
11
Distinct published reports
Individual concerns
15
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
16
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England3
East Kent Hospitals University NHS Foundation Trust2
National Institute for Health and Care Excellence2
Bedfordshire Hospitals NHS Foundation Trust1
Bourne Leisure Limited1
Calderdale and Huddersfield NHS Foundation Trust1
Cardiff & Vale University LHB1
Care Quality Commission1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
East Lancashire Hospitals NHS Trust1
East Sussex Healthcare NHS Trust1
Farnham Medical Centre1
Leeds Teaching Hospitals NHS Trust1
Luton and Dunstable University Hospital1
NHS trust8
Executive non-departmental public body3
Devolved government1
Health and social care service regulator1
Healthcare site1
Integrated care board1
Local health board1
Ministerial department1
Private limited company1
Social-care provider1
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.
City of London
Concerns raised1
Lack of timely tertiary-centre involvement in care planning for patients requiring pacemaker lead extraction
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.
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
Action
Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 August 2026.
Action
Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The specialist extraction centre, in consultation with the patient, makes the final decision about whether and when lead extraction occurs.
Stated by East Kent Hospitals University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Wales Central
Concerns raised2
Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre
Delays in seeking specialist advice and transferring patients to a tertiary centre
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.8
Action
Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.
Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Reinforce the expectation of early consultant-level discussion for suspected bile duct injury and complex benign HPB cases.
Stated by The Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Remind relevant partners to use the existing HPB escalation framework, designated contacts and urgent advice procedures, and consider timely transfer.
Stated by The Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Use focused communication and education to reinforce referral and escalation principles for suspected bile duct injury.
Stated by The Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
Action
Develop and disseminate a formal regional escalation and referral framework specifying triggers, discussion timescales, contacts and transfer expectations.
Stated by The Health BoardStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Embed learning through clinical governance, oversee implementation of revised escalation arrangements, confirm communication, and test compliance through audit or case review.
Stated by The Health BoardStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.
Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Established clinical standards provide guidance; the principal failure was inconsistent application, not absence of specialist knowledge or access.
Stated by The Health BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex
Concerns raised2
Lack of guidance for urgent referral of children to hospital or tertiary care
Delays in reassessment and referral of urgent cases due to inadequate cover
This report raised 12 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.
Birmingham and Solihull
Concerns raised1
Failure to make timely VITT specialist referral and transfer arrangements
This report raised 3 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Provide regulators with assurance about appropriate referral of future patients to tertiary services.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Inner West London
Concerns raised1
Lack of a designated referral pathway for children with achondroplasia
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to expedite scanning or contact tertiary neurosurgical services after specialist input
This report raised 16 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Operate a year-round radiology inpatient coordinator or navigator function to improve referral communication, patient flow and scan escalation.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
Action
Develop a standard operating procedure defining navigator functions and referrer actions for radiology access and efficiency.
Stated by East Lancashire Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 March 2021.
Action
Hold twice-weekly clinico-radiological meetings to discuss difficult cases and support imaging decisions without requiring personal attendance.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2021.
West Yorkshire Eastern
Concerns raised1
Lack of clarity about information required in electronic referrals
This report raised 8 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.
Inner West London
Concerns raised2
Failure to refer high-risk asthma patients to tertiary respiratory services
Failure to complete formal referral to a tertiary respiratory service
This report raised 23 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.
Gateshead and South Tyneside
Concerns raised2
Failure to enable appropriate referrals to the tertiary paediatric service
Failure to refer paediatric asthma patients to tertiary respiratory specialists
This report raised 7 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.
Central and South East Kent
Concerns raised1
Failure to refer high-risk patients to a Tertiary Centre for second opinion and management
This report raised 3 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.
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Includes failures in arrangements for recognising when tertiary specialist referral is needed, defining referral thresholds or routes, initiating and communicating the referral, and ensuring the receiving tertiary service can provide timely specialist advice or accept the referral.
