Recurring concern

Unreliable referral urgency categorisation and prioritisation

First to latest report 27 Dec 2013 — 17 Apr 2025

Reports that mention this concern
12
Times this concern has been raised
15
Stated actions linked to this concern
27

What this concern includes

Includes failures in the process for categorising, validating, prioritising or re-prioritising Emergency, Urgent and Routine referrals, including unclear or imprecise urgency guidance, categorisation by unqualified personnel, failure to review the assigned category, and failure to raise priority after failed contact or other material risk information.

What is not included
  • Excludes delays or failures in referral assessment, treatment or follow-up where the referral urgency categorisation and prioritisation process was reliable.
  • Excludes generic staffing, workload, communication or documentation deficiencies unless they directly impair referral urgency categorisation or prioritisation.
  • Excludes ambulance, emergency-department, specialist and mental-health triage systems unless the assertion specifically concerns the same referral-urgency categorisation and prioritisation process.
  • Excludes the substantive quality of care provided after an appropriately prioritised referral has been accepted.

Reports and published responses 12 reports

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

  1. Essex

    AI-generated summary

    Linda Sitch · 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

    Linda took her own life on 11 November 2023 after prolonged strain associated with caring for her husband, who had significant physical and mental health problems. Adult Social Care did not substantively respond to safeguarding and carer assessment referrals or the family’s escalating concerns before her death. The report raises concerns about inadequate oversight and the risk that urgent referrals could be inappropriately downgraded or insufficiently reviewed, potentially contributing to future deaths.

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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 ensure thorough, professional and adequately documented review of urgent referral grading

    Wider context from the report

    “d. In contrast to this view, I remain concerned that ASC continues to lack a robust system to ensure sufficiently rigorous oversight, including active auditing, capable of identifying the kind of sub-optimal managerial level performance as has been brought to the fore in this case. A change in personnel and moves towards “embedding best practice” do not, in my opinion, sufficiently address this systemic lacuna given that the effectiveness of such changes will still rely very substantially upon the performance of any Team Manager and/or a Deputy Team Manager. There appears to me to be a continuing lack of robust Service level oversight of those managers themselves, (including the appropriateness of their decision making), absent which any sub-optimal performance by said managers may well not be identified. e. Absent a sufficiently robust system for providing oversight and identifying and significantly mitigating (if not entirely removing) such individual human error, alongside, for example, the inclusion of simple auditable check lists of matters to be accessed, reviewed and documented whenever a referral is received, then there is a continuing risk of urgent future referrals being inappropriately graded as Priority 2 (and/or being downgraded from Priority 1) without the requisite thorough and professional review, adequately documented, being undertaken. This gives rise to a concomitant risk of future deaths. ”

    Source location

    Linda Sitch · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Introduce carers practice guidance and core practice guidance covering assessments, reviews, support planning and safeguarding.

    Verbatim wording from the response

    “• New Carers practice guidance for Adult Social Care operational workers to support better and more timely outcomes for carers.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 28 April 2025

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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

    Implement risk-priority matrices for carers’ assessments, reviews and safeguarding referrals.

    Verbatim wording from the response

    “• A new Risk Priority Matrix for carers assessments and reviews was implemented in 2023, which was being embedded throughout the year.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 28 April 2025

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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

    Conduct a scheduled audit of referral progression through allocation and consider issuing further guidance on priority decisions and allocation timescales.

    Verbatim wording from the response

    “Adult Social Care have scheduled an audit cycle within the next three months, specifically focused on how referrals are progressed when an initial referral is received, through to point of allocation. Following analysis and outcomes of this, we will consider issuing further practice guidance to confirm expectations about making good, defensible decisions around priority levels, including expected timescale for the allocation of work.”

    Source location

    Response from Essex County Council
    Page 3 · response
    Published 28 April 2025

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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

    Refresh the Quality Assurance Framework and conduct eight annual audit cycles covering assessments, reviews, mental capacity and safeguarding, with findings reported to the Practice Governance Board.

    Verbatim wording from the response

    “Alongside the Quality Control measures in place, Adult Social Care refreshed its Quality Assurance Framework in 2024 and there are now eight audit cycles in place throughout every year. These focus on care act assessments/reviews, carers assessments, mental capacity assessments and safeguarding. Audits are analysed and reports are presented to the Practice Governance Board.”

    Source location

    Response from Essex County Council
    Page 5 · response
    Published 28 April 2025

    Open published response

  2. South Wales Central

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    Sara GRINNELL · 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

    Sara Grinnell experienced excessive vaginal bleeding and menorrhagia, with repeated referrals to gynaecology before being diagnosed with endometrial cancer in June 2021. A planned hysterectomy was postponed, her treatment options became palliative, and she died on 11 April 2022. The principal concerns were delays exceeding 22 weeks in contacting her after an urgent referral, reliance on written correspondence without further contact methods, insufficient regard to earlier referrals, and a 24-month delay between urgent referral and diagnosis.

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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 account for earlier referrals and existing delays when reassessing urgency of gynaecology contact

    Wider context from the report

    “(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment. (2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P. (3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact. (3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis. ”

    Source location

    Sara GRINNELL · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Update triage procedures and implement electronic triage to support consistent 24–48-hour allocation.

    Verbatim wording from the response

    “Improve triaging process; update the triage proforma, agreement of daily triage allocation; implementation of electronic triage (WPRS)”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 2024

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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

    Hold CTM gynaecology cancer oversight meetings to review performance, patients, escalations and waiting times.

    Verbatim wording from the response

    “Establish CTM Gynae cancer oversight meetings (implemented from 11th May)”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 2024

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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

    Strengthen harm reviews through robust clinical MDT review of patients waiting more than 104 days.

    Verbatim wording from the response

    “Improve harm review process”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 2024

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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 Health Board disputes that the re-referral met urgent suspected cancer criteria, stating the case was reviewed by the GP and a specialist.

    Verbatim wording from the response

    “3) When the G.P. re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 3 · response
    Published 17 September 2024

    Open published response

  3. Suffolk

    AI-generated summary

    Ellen Ocean WOOLNOUGH · 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

    Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

    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

    Inadequate decision making when downgrading urgent referrals

    Wider context from the report

    “2. The adequacy of NSFT’s Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals. ”

    Source location

    Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 updated Trust-wide CRHTT SOP and Clinical Harm Review SOP requirements for discussing urgent-referral regrading with another clinician.

    Verbatim wording from the response

    “3. The Trust Standard Operating Procedure (SOP) addressing the downgrading of urgent referrals, which I was told was revised in 2023, has not been provided to the Court and has not been implemented by the Trust.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 15 April 2024

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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

    Evaluate compliance with two-clinician referral regrading through management monitoring and a Patient Safety and Quality Team audit, with results reported through quality-assurance structures.

    Verbatim wording from the response

    “We will evaluate compliance against this standard through local management monitoring with additional second level assurance provided through an audit that will be completed by the Patient Safety and Quality Team by mid-July 2024. This will enable us to provide assurance that all decisions to regrade a referral are being made by two clinicians in line with Trust standard.”

    Source location

    Response from Norfolk and Suffolk NHS Foundation Trust
    Page 2 · response
    Published 15 April 2024

    Open published response

  4. West Sussex

    AI-generated summary

    James Joseph MANNING · 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 Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

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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

    Lack of guidance for urgent referral of children to hospital or tertiary care

    Wider context from the report

    “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding: i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide. ”

    Source location

    James Joseph MANNING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Surrey

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    OSKAR MILES NASH · 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

    Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.

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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

    Automatic categorisation of routine referrals as low risk

    Wider context from the report

    “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk”. I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged. ”

    Source location

    OSKAR MILES NASH · Prevention of Future Deaths report
    Page 4 · concerns

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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

    Apply harm reviews to routine referrals waiting over four weeks and review continuing waits every four weeks until triage.

    Verbatim wording from the response

    “If a routine referral has been waiting for over four weeks to be triaged, then it is now subject to a harm review. The child/young person and/or their family will be contacted as part of this, and there will be a conversation about what the current situation is and whether there are any increased risks. Following this review, the referral will either be categorised as being suitable and safe to remain in the routine referral waiting list, with safety netting advice being provided. Alternatively, if the risks have escalated, the referral will be triaged immediately and then referred on to an appropriate service.”

    Source location

    2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
    Page 3 · response
    Published 3 February 2022

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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 and approve the Standard Operating Procedure manual to reflect new referral triage practices.

    Verbatim wording from the response

    “Concern 4 I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance.”

    Source location

    2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
    Page 7 · response
    Published 3 February 2022

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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

    Routine referrals are not automatically treated as low risk; they are screened as low risk only after assessment and confirmation of protective factors.

    Verbatim wording from the response

    “I have been told that the routine referrals are automatically categorised as “low risk”. … It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.”

    Source location

    2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
    Page 7 · response
    Published 3 February 2022

    Open published response

  6. Milton Keynes

    AI-generated summary

    Roy Adrian CURTIS · 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

    Roy Adrian CURTIS, who had an autistic spectrum condition, was admitted after declaring an intention to take his own life and was later discharged without a formal multidisciplinary discharge plan. He died by suicide by hanging on or about 18 November 2018, and his body was discovered on 21 August 2019. The report raises concerns about the failure to complete an adult social care assessment and the overly bureaucratic procedure for urgent referrals, which did not give such referrals sufficient priority.

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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 give urgent adult social care assessment referrals sufficient priority within social services

    Wider context from the report

    “That the procedure for allocating and responding to a referral for an urgent adult social care assessment is overly bureaucratic and they are not afforded the priority within social services that they so obviously require. ”

    Source location

    Roy Adrian CURTIS · Prevention of Future Deaths report
    Page 1 · concerns

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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

    Embed identification of inpatients needing social care support in discharge planning to enable timely assessment before discharge.

    Verbatim wording from the response

    “Mr Curtis should have been seen and offered an assessment whilst still an inpatient at the Campbell Centre, an approach that is now well embedded across health and social care. Identifying people who are in patients who need support are in discharge planning meetings and is now straightforward and should not be subject to any delays or unnecessary bureaucracy.”

    Source location

    2020-0272-Response-from-Milton-Keynes-Council-Redacted
    Page 1 · response
    Published 5 January 2021

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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

    Employ a link social worker for the acute mental health ward to coordinate required social care assessments before discharge.

    Verbatim wording from the response

    “We recognise that we did not get our response right for Mr Curtis. We have learnt from his untimely death and have reviewed and improved our practice. There is now a link social worker employed to work with the acute mental health hospital ward who is responsible for coordinating social care assessments before discharge when needed.”

    Source location

    2020-0272-Response-from-Milton-Keynes-Council-Redacted
    Page 2 · response
    Published 5 January 2021

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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

    Monitor team practice and monthly performance, including assessment timelines and casework reviews, through the Adult Leadership Team.

    Verbatim wording from the response

    “We will continue to monitor the practice of our teams, with a focus on learning and improving outcomes for vulnerable people. We formally review our performance each month via our Adult Leadership Team meeting, with Heads of Service responsible for the performance in their area. This monitoring includes the timelines for assessments and case work review.”

    Source location

    2020-0272-Response-from-Milton-Keynes-Council-Redacted
    Page 3 · response
    Published 5 January 2021

    Open published response

  7. East London

    AI-generated summary

    Lee Leslie Carpenter · 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

    Lee Leslie Carpenter took his own life on 1 October 2019 after being referred by his GP to mental health services for an urgent review. Concerns included the referral being triaged as non-urgent without a documented rationale or discussion with Mr Carpenter or the GP, a lack of robust risk assessment, care planning and medication review, and the absence of a response when the Home Treatment Team visited his home on the day of his death. The report also identified no system for clearly documenting important clinical triage decisions or identifying the staff member responsible.

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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 discuss downgraded GP referral urgency with the patient or GP

    Wider context from the report

    “The matter of concern during the course of the Inquest, was that a GP had made a referral to the mental health team requesting an urgent review of Mr Carpenter. This was sent on the 9th August 2019 to the Havering Access Assessment and Brief Intervention Team. The referral was received on the same date and appears to have been triaged for a non-urgent response. The decision determining the non-urgent response was not documented. There was no documented rationale for overriding the GP’s request for an urgent review. There was no discussion with the patient or the GP before the decision to downgrade the urgency. The member of staff who made the decision was not identified within the medical records. The first telephone assessment of Mr Carpenter did not take place until the 23rd August 2019. As at the date of the Inquest, there is no system in place within the Trust for important clinical decision relating to the triage of GP referrals to be clearly documented within patient records and for the member of staff making the decision, to be clearly identified and accountable. ”

    Source location

    Lee Leslie Carpenter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Cheshire

    AI-generated summary

    David Moran · 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 Moran, who had bipolar affective disorder and a history including suicide attempt and suicidal ideation, died after taking a fatal overdose of metformin; the inquest could not determine his intention. Concerns included imprecise referral-priority guidance, the absence of a default urgent response when screening was not possible or the situation was ambiguous, and ineffective communication between administrative and clinical staff.

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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

    Imprecise guidance for categorising referral urgency

    Wider context from the report

    “(1) The Trust Guidance for categorising the urgency of a referral appeared imprecise. Further, in that the referral system will often depend on a telephone conversation only, there did not appear to be a default to urgent in a case where a screening assessment was not possible or in a case of doubt or ambiguity. ”

    Source location

    David Moran · Prevention of Future Deaths report
    Page 1 · concerns

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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 telephone triage system and supporting procedures, including urgent face-to-face assessment within 72 hours where triage is uncertain or refused.

    Verbatim wording from the response

    “Since August 2016 a clinical project group has been developing a telephone triage system for the Assessment Team and this has been piloted in Warrington in December 2016. The project has been positively evaluated and Standard Operating Procedures developed to support the roll-out of this initiative.”

    Source location

    2017-0008-Response-by-5-Borough-Partnership-NHS-trust
    Page 2 · response
    Published 19 February 2017

    Open published response

  9. Surrey

    AI-generated summary

    Vanessa Christine DADSWELL · 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

    Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.

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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

    Lack of an intermediate urgent mental health referral timeframe

    Wider context from the report

    “During the course of the inquest the evidence revealed that any urgent referral by a GP would be categorised by West Sussex Community Mental Health as either as a ‘4 hour’ referral or as a ‘within 5 day’ referral. A ‘4 hour’ referral would involve the service user having to attend A&E urgently for an assessment within 4 hours. A ‘within 5 day referral’ was exactly as described, an appointment within 5 days. The issue arose where a referring GP did not consider it necessary nor appropriate for a 4 hour referral and yet believed a 24 hour visit was necessary as 5 days would be too long. The deceased was not seen within 24 hours and committed suicide 3 days after the referral with no direct contact having been made. Evidence given by the Service manager for the Trust agreed that an intermediate option for referral would not be unreasonable. Consideration should be given to an alternative, intermediate referral time between the current ‘4 hour’ and ‘within 5 day’ periods for referrals together with effective management thereof. ”

    Source location

    Vanessa Christine DADSWELL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 Triage Team Leaders to book priority appointments directly.

    Verbatim wording from the response

    “• Triage Team Leaders now have direct bookable Priority Appointment slots and do not need to pass priority referrals to the Assessment & Treatment Duty Worker for booking.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

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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

    Require daily review of out-of-hours referrals and arrange appointments within 24 hours when clinically indicated.

    Verbatim wording from the response

    “• Every morning the Triage Team Leader assesses all incoming referrals received out of hours and, if the referrer has requested the service user to be seen within 24 hours but did not consider a 4 hour response was clinically required, appointments within 24 hours are arranged.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

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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

    Fast-track referrals to the first available appointment based on risk assessment.

    Verbatim wording from the response

    “• Referrals can be fast track allocated by the Triage Team Leader so they do not wait up to 5 days for a slot; they are given the first available appointment, dependent on assessment of risk, often within 2–3 days.”

    Source location

    Vanessa-DADSWELL-Response
    Page 1 · response
    Published 17 February 2016

    Open published response

    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

    Develop a Coastal West Sussex protocol documenting the improved referral system, with the inquest checklist and flowchart appended.

    Verbatim wording from the response

    “Penny Fenton, General Manager Coastal West Sussex Care Delivery Service (CDS), Nadia Anderson, Service Manager Western, Working Age Mental Health Services, Coastal West Sussex Care Delivery Service (CDS) and Liam Rudden, Service Manager for Adur, Arun & Worthing Assessment and Treatment Service are currently drafting a protocol encompassing the improved system throughout Coastal West Sussex CDS. The checklist and flowchart developed and exhibited at the inquest will be appended so there is a clear user friendly guide for staff. Dr Brian Solts, Divisional Clinical Director – Coastal West Sussex Care Delivery Service (CDS) has confirmed he will present the protocol, together with the learning from Mrs Dadswell’s inquest, to the Adult Management Board to maximize learning and embed the improvements introduced.”

    Source location

    Vanessa-DADSWELL-Response
    Page 2 · response
    Published 17 February 2016

    Open published response

    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

    Meet West Sussex mental health commissioners to jointly review the urgent care pathway in light of the improvements and current practice.

    Verbatim wording from the response

    “The Service Specification for the Urgent Care Pathway detailing the 4 hour and 5 day referral options was developed in partnership with our West Sussex Commissioners and is due for renewal. Dr Solts has requested a meeting to be arranged with the West Sussex Mental Health commissioners to review the pathway jointly with us, in light of the improvements we have made, and the greater flexibility we have introduced, so it reflects current practice.”

    Source location

    Vanessa-DADSWELL-Response
    Page 2 · response
    Published 17 February 2016

    Open published response

  10. Avon

    AI-generated summary

    Ms. Marilyn Anson · 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

    Ms. Marilyn Anson had diabetes and end-stage renal failure requiring dialysis, and developed a severe left-foot pressure ulcer. An urgent referral to the ‘hot foot’ clinic was made on 26 February 2015, but the earliest appointment offered was 17 March; the ulcer deteriorated, requiring hospital admission, antibiotics and amputation surgery, and she died after further surgery on 22 March 2015. The concerns included the prioritisation and resourcing of the clinic, coordination between relevant organisations, and guidance and standardisation of referrals.

    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 prioritising urgent referrals to the ‘hot foot’ clinic

    Wider context from the report

    “(1) An urgent referral was made by the community nurses to the ‘hot foot’ clinic on 26th February 2015 and no appointment could be offered until 17th March 2015. (2) Before this appointment date the deceased’s ulcer had deteriorated and she had been admitted to hospital where she later died. (3) There should be a review of the means by which patients who are referred to this clinic are prioritised. (4) There should be a review of the resources allocated to this clinic in the light of demand from new and follow-up patients. (5) The NSCP should collaborate with Weston Area Health Trust and other relevant stakeholders to ensure current and future resources are used efficiently and effectively. (6) There should be provided guidance to those who refer patients to this clinic with regard to referring patients to this clinic and other options for assessment and treatment as well as a standardised means of referral so that all patients are prioritised according to clinical need. ”

    Source location

    Ms. Marilyn Anson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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