Recurring concern

Unreliable and delayed surgical referral and review

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First reported 25 Feb 2014•Latest report 29 Dec 2023

Definition

What this concern includes

Includes failures of the surgical referral-and-review process, including referral completion, handover, escalation, availability or responsiveness of surgical services, and timeliness of review, where these failures prevent or delay required surgical input.

Not included

  • Excludes generic delays in treatment, imaging, transfer or other clinical processes without a direct surgical referral or review connection.
  • Excludes failures concerning postoperative follow-up or ongoing oversight after discharge when they are not part of an outstanding surgical referral or review.
  • Excludes documentation, training or staffing deficiencies that are not specifically tied to failure of the surgical referral-and-review process.
Reports
12

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2014–2023

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.

Royal London Hospital2
Barts Health NHS Trust1
British Renal Society1
Calderdale and Huddersfield NHS Foundation Trust1
Care Quality Commission1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
East Lancashire Hospitals NHS Trust1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Homerton Healthcare NHS Foundation Trust1
Joint Royal Colleges Ambulance Liaison Committee1
Kindandental1
Leeds Teaching Hospitals NHS Trust1
NHS England1

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.

  1. Central and South East Kent

    AI-generated summary

    William Albert Winter · 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

    William Albert Winter was admitted to hospital after discharge from St Thomas’ Hospital following surgery for repair of an abdominal aortic aneurysm, and was found unresponsive with rigor mortis at approximately 5am on 26th March 2013. Nursing staff were concerned that he had not been reviewed by the surgical team, and a second set of observations was not carried out or escalated as required amid pressures on the Clinical Decisions Unit.

    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 escalate outstanding requests for surgical review

    Wider context from the report

    “Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team. They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in an unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed. I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review. They were unfamiliar with how to do this. ”

    Source location

    William Albert Winter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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

    Delays in surgical review after referral

    Wider context from the report

    “(1) Delay in being seen both by Nursing Staff and Doctors in A & E. Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013. Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026