Recurring concern

Unreliable referrals to tertiary specialist services

First to latest report 2 Jun 2014 — 25 Jun 2026

Reports that mention this concern
11
Times this concern has been raised
15
Stated actions linked to this concern
16

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Bedfordshire and Luton

    AI-generated summary

    Aimee Sarah VARNEY · 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

    Aimee Sarah VARNEY died following a seizure from Sudden Unexpected Death in Epilepsy at her home address. The report identifies a concern that NICE guidance on referring patients with suspected epilepsy to a Specialist Tertiary Centre was not followed, and states that this represented a lost opportunity to diagnose and further treat her condition.

    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 follow NICE referral guidelines for patients with suspected epilepsy to a Specialist Tertiary Centre

    Wider context from the report

    “1. That the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed. ”

    Source location

    Aimee Sarah VARNEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NICE guidelines do not require rigid compliance; clinicians may appropriately depart from recommendations using professional clinical judgment.

    Verbatim wording from the response

    “However it must be emphasised that they are guidelines, not tramlines that the treating clinician must rigidly follow. NICE state “...health and social care professionals are actively encouraged to follow our recommendations to help them deliver the highest quality care. Of course, our recommendations are not intended to replace the professional expertise and clinical judgement of health professionals, as they discuss treatment options with their patients.” There will be individual patients where the treating clinician uses their own judgement and does not follow the absolute guidance.”

    Source location

    2014-0249-Response-by-Luton-Dunstable-University-Hospital
    Page 2 · response
    Published 2 June 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

    Existing systems for logging, disseminating and monitoring NICE guidelines are considered appropriate.

    Verbatim wording from the response

    “The Medical Director is responsible for ensuring every new NICE guideline is allocated to the relevant speciality. The appropriate Clinical Audit and Effectiveness Committee (CAEC) Lead, the Finance and the Clinical Director all receive copies for discussion and dissemination. As for all NHS bodies there are occasions where the hospital cannot immediately comply with NICE guidance. This can be due to resources and requires negotiation with our commissioners to fund, for example, high value new drug therapies.”

    Source location

    2014-0249-Response-by-Luton-Dunstable-University-Hospital
    Page 1 · response
    Published 2 June 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026