Recurring concern

Unreliable clinical second-opinion processes

First to latest report 20 Dec 2013 — 27 Feb 2026

Reports that mention this concern
10
Times this concern has been raised
11
Stated actions linked to this concern
10

What this concern includes

Includes failures in clinical second-opinion arrangements, including establishing a formal route, informing patients and families how to request one, supporting and processing requests, seeking an alternative consultant opinion when warranted, and truthfully recording or communicating whether a second opinion was obtained.

What is not included
  • Excludes generic clinical escalation, consultation or senior-review failures where no second-opinion request or process is identified.
  • Excludes ordinary referral or specialist-access delays unrelated to seeking an alternative clinical opinion.
  • Excludes failures in the quality of the original diagnosis or treatment unless they also concern access to, conduct of or truthful communication about a second opinion.
  • Excludes legal, employment or non-clinical opinions and reviews.

Reports and published responses 10 reports

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

  1. Essex

    AI-generated summary

    David James FENN · 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 James FENN was admitted to hospital with suspected sepsis and septic left knee arthritis, after attending several days earlier with similar symptoms and being discharged home. He subsequently developed severe sepsis and multiorgan failure and died on 12 February 2025. The principal concerns were that sepsis was not appropriately recognised on 28 January, the Sepsis 6 pathway was not followed, timely consultant review was not obtained, and relevant clinical discussions and escalation did not occur adequately.

    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 seek an alternative Consultant's opinion

    Wider context from the report

    “5) An alternative Consultant's opinion was not sought. ”

    Source location

    David James FENN · 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 Martha’s Rule, including daily patient check-ins, rapid review access and advertised escalation routes for concerns about deterioration, treatment or discharge planning.

    Verbatim wording from the response

    “In addition to the above, the Trust has implemented ‘Martha’s Rule’, which allows patients, families, carers and staff to request a rapid clinical review if they are concerned about a patient’s deteriorating condition. It covers communication issues and ensures that concerns about medication, investigations, or discharge planning are resolved. The three core elements of the Rule are:”

    Source location

    Response from East Sussex and North Essex NHS Foundation Trust
    Page 4 · response
    Published 18 March 2026

    Open published response

  2. Inner West London

    AI-generated summary

    Samuel Finlay Parkin · 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

    Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.

    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 obtain fresh specialist review of gastroenterology re-referrals

    Wider context from the report

    “5. One of the learning actions taken by St George’s is that re-referrals to gastroenterology are reviewed by another consultant in order that a fresh assessment/second opinion may occur, followed by an MDT discussion and the option of transferring back to the original consultant. St George’s feels this may help increase the detection of atypical/unusual presentation of GI conditions, including a later presentation of malrotation. Action is required so that this learning point is considered across the NHS. ”

    Source location

    Samuel Finlay Parkin · 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

    Update the national paediatric gastroenterology service specification to reference second-opinion guidance and strengthen multidisciplinary communication and discussion of unexpected investigation results.

    Verbatim wording from the response

    “NHS England Specialised Commissioning will soon begin work to update the published national service specification on Paediatric Gastroenterology, Hepatology and Nutrition which outlines standards for specialised paediatric gastroenterology services. The updated service specification will reference the guidance produced on the provision of second opinions and will also ensure that the importance of communication between multi-disciplinary teams, including surgical, paediatric and paediatric gastroenterology teams, is highlighted. This will include the need for multi-disciplinary discussion for all patients where the results of investigations are not as anticipated.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 22 July 2025

    Open published response

  3. Inner North London

    AI-generated summary

    Riya HIRANI · 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

    Riya Hirani, aged nine, was transferred to Great Ormond Street Hospital after presenting in cardiac arrest, having previously been assessed and discharged from Northwick Park Hospital. The concerns were that the severity of her illness was not recognised, despite her mother's repeated concerns, and that she was not given intravenous antibiotics, admitted, or escalated for a second opinion. Riya died five days after the cardiac arrest; her recorded cause of death included hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest, invasive group A streptococcal infection and influenza B infection.

    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 seek or provide ready access to a second medical opinion when serious illness is disputed

    Wider context from the report

    “Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats. I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally. When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.) I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation. One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends. Although the events bringing the two children to hospital were very different, as I listened to the evidence at Riya’s inquest I noticed some striking similarities between the circumstances of Riya’s treatment and those of Martha Mills. On each occasion a parent’s articulately expressed and ultimately prescient concerns about a previously healthy but rapidly deteriorating child, did not result in appropriate escalation of care. I heard the inquest touching Martha’s death last year. I am aware from press reports of the attempts of Martha’s mother to enable families in such a situation to have ready access to a second medical opinion. It seems to me that you should be aware of the circumstances of Riya’s death before you decide how to proceed. ”

    Source location

    Riya HIRANI · 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

    Develop, ratify, disseminate and audit a paediatric examination SOP covering escalation, SBAR handovers, senior opinions and mandatory face-to-face review before discharge.

    Verbatim wording from the response

    “New standard operating procedure”

    Source location

    Response from London North West University Healthcare NHS Trust
    Page 1 · response
    Published 22 September 2023

    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

    Advise clinicians to seek senior review when caregivers remain concerned after clinical review.

    Verbatim wording from the response

    “As an interim measure pending completion of the SOP all clinicians have been advised through multi professional meetings and via email communication that if a caregiver raises concerns following clinical review the clinician should have a low threshold for seeking senior review.”

    Source location

    Response from London North West University Healthcare NHS Trust
    Page 2 · response
    Published 22 September 2023

    Open published response

  4. Manchester North

    AI-generated summary

    Angela Marie FROST · 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

    Angela Marie FROST was admitted to hospital after a mixed overdose and later went missing with the intention of starving herself to death. She was found at home on 24 August 2020 after taking an intentional overdose of her partner’s old medication; the inquest recorded the medical cause of death as amitriptyline overdose and concluded suicide whilst the balance of her mind was disturbed. The principal concerns included the absence of formal processes for seeking second opinions and inadequate understanding of confidentiality and permissible communication with family members.

    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

    Lack of a formal second-opinion process for Consultant Psychiatrists

    Wider context from the report

    “(1) There is no formal guidance or process in place at the Trust for Consultant Psychiatrists to seek a second opinion in relation to diagnosis, treatment plans or whether a patient meets the criteria for detention under the Mental Health Act. The evidence was that whilst there is nothing to prohibit a Consultant requesting a second opinion, it rarely happens in practice. ”

    Source location

    Angela Marie FROST · Prevention of Future Deaths report
    Page 2 · concerns

    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

    Lack of a formal second-opinion process for health care professionals or family members

    Wider context from the report

    “(2) There is no formal guidance or process in place at the Trust for health care professionals or family members to seek a second opinion in relation to the matters set out above. ”

    Source location

    Angela Marie FROST · 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

    Write a formal process enabling consultants, healthcare professionals, patients, families and carers to request second opinions.

    Verbatim wording from the response

    “Since Ms Frost's untimely death, the Triumvirate Leadership Team for Oldham's Mental Health Services has reviewed the Trusts internal processes to request second opinions. Below is a summary of the work that has been done so far:”

    Source location

    2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 2 June 2021

    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

    Submit the drafted second-opinion process to the Trust Quality Group for scrutiny and sign-off.

    Verbatim wording from the response

    “- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion. - The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.”

    Source location

    2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 2 June 2021

    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

    Implement the second-opinion process across all Trust services.

    Verbatim wording from the response

    “- A draft process for requesting second opinions has been written, and this will be submitted to the Trusts Quality Group for scrutiny and sign-off. The process includes guidance for how Consultant Psychiatrists, Health Care Professionals, patients, families and carers can request a second opinion. - The process will be implemented across all of Pennine Care NHS Foundation Trust's (PCFT's) services.”

    Source location

    2021-0183-Response-from-Pennine-Care-NHS-Foundation-Trust_Published
    Page 1 · response
    Published 2 June 2021

    Open published response

  5. East London

    AI-generated summary

    Trinder Kaur Birdi · 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

    Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.

    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 obtain and document a second psychiatric opinion before downgrading suicide risk

    Wider context from the report

    “The general practitioner who had known Ms Birdi over a number of years and had seen her for multiple mental health consultations had raised concerns with the A & E psychiatric team that Ms Birdi was at a high risk of suicide. The GP considered that Ms Birdi required an urgent psychiatric assessment and that Ms Birdi was at a high risk of taking a further overdose with a higher number of tablets. Following assessment, the same day, by a psychiatric liaison nurse who had never met the deceased before, the risk to self was reduced to low. The risk was lowered from high to low, without any consultation with the general practitioner or second opinion sought and documented from a fellow psychiatric professional. It is concerning that the risk to self can be downgraded by a member of staff, new to the patient, following referral from a doctor who knows the patient well. There were no safeguards in place for this circumstance, such as a discussion with the referring general practitioner, second opinion from a fellow psychiatric clinician or assessment by a psychiatric doctor. ”

    Source location

    Trinder Kaur Birdi · 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

    Introduce referral to the on-call psychiatrist when presenting risk significantly differs from another clinician’s same-day assessment.

    Verbatim wording from the response

    “1. A requirement will be introduced for a referral to the on-call psychiatrist to be completed where the presenting risk is significantly different to that of another clinician (including GP) who has reviewed the patient on the same day.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    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

    Review Clinical Risk Advanced training to include differing clinical opinion scenarios and guidance on addressing them.

    Verbatim wording from the response

    “5. A review of the Clinical Risk Advanced level training to include case scenarios that indicate a difference in clinical opinion, and to reiterate guidance how to address these scenarios.”

    Source location

    2020-0252-Response-from-North-East-London-Foundation-Trust-Redacted.pdf
    Page 3 · response
    Published 29 December 2020

    Open published response

  6. Manchester (North)

    AI-generated summary

    Susan Beverley George · 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

    Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

    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

    Staff unawareness of how to support patients seeking a second medical opinion

    Wider context from the report

    “8. Staff were unaware of how to support and advise patients on the issue of obtaining a second medical opinion where the patient disagrees with the first doctor’s decision (in this case, to proceed to discharge). ”

    Source location

    Susan Beverley George · Prevention of Future Deaths report
    Page 3 · 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

    Develop staff briefing and guidance on accessing support, advocacy, second opinions, Triangle of Care principles and multidisciplinary-team involvement.

    Verbatim wording from the response

    “To develop a briefing on guidelines for staff to follow on how service users can access support if they are unhappy with the decision made about their care.”

    Source location

    Susan-George-Response
    Page 6 · response
    Published 29 February 2016

    Open published response

  7. Inner West London

    AI-generated summary

    Mr Tommy Faegh Faisali · 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 Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.

    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 ensure that psychiatric second-opinion referrals are assessed by appropriately qualified psychiatrists

    Wider context from the report

    “(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral. (2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals. (3) Those patients may be at increased risk because of (1) and (2) above. ”

    Source location

    Mr Tommy Faegh Faisali · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Central and South East Kent

    AI-generated summary

    Betty SMITH · 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

    Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising care.

    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 refer high-risk patients to a Tertiary Centre for second opinion and management

    Wider context from the report

    “• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management. ”

    Source location

    Betty SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. North Wales (East and Central)

    AI-generated summary

    Clive Harold Turner · 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

    Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.

    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

    Unavailability of senior clinicians for overnight second opinions

    Wider context from the report

    “That ████████SHO in Emergency Medicine indicated in her evidence as follows :- 1. that she did not know what pain relief had been provided to Mr Turner by the Welsh Ambulance Service 2. that she was not aware of any policies within BCUHB relating to the discharge of patients overnight. 3. that there were no senior clinicians on duty from whom she could seek a second opinion due to the lateness of the hour when she was attending to Mr Turner. ”

    Source location

    Clive Harold Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. North Wales (East and Central)

    AI-generated summary

    Kate Louise PIERCE · 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

    Kate Louise PIERCE died on 14 March 2013, aged 7, following complications associated with meningitis, including acquired cerebral palsy, epilepsy and chronic lung disease. The report raised concerns about the handling of her diagnosis at Wrexham Maelor Hospital and whether a doctor misled her parents about obtaining a second opinion. It also raised concerns about that doctor's fitness to practise and continued work as a GP, identifying a risk of future deaths.

    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 provide truthful information about seeking clinical second opinions

    Wider context from the report

    “On the 29th of March 2006 Kate was taken into the Wrexham Maelor Hospital where she was examined by a Dr ████████. It appears from the evidence available that he failed to deal correctly with the diagnosis of Kate's condition and furthermore there is a belief that he may have misled the parents of Kate by indicating that he had sought a second opinion from a colleague before discharging her when this was not in fact the case. I understand that enquiries were made previously by the GMC following a complaint against Dr ████████ but that no action has been taken due to legal action by the Dr in view of the elapse of a relevant time limit. In the course of my current investigation following Kate’s death, a statement has been obtained from a witness namely Dr ████████ and a copy of this is annexed hereto. My view is that this statement casts doubt on Dr ████████ fitness to practice and this is of grave concern as my understanding is that he currently continues to practice as a GP within my Corner Area. In view of this I consider that there is a risk of future deaths. ”

    Source location

    Kate Louise PIERCE · Prevention of Future Deaths report
    Page 1 · 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

    The five-year statutory rule and unsuccessful exceptional-circumstances test prevented further investigation of the historical events and audit.

    Verbatim wording from the response

    “We considered the complaint by Mr ████████ in accordance with our statutory framework and initially decided to investigate the case although the events at that time were more than five years old. Our statutory rules preclude us from investigating events that are more than five years old unless it is in the public interest in the exceptional circumstances to do so.”

    Source location

    2013-0363-Response-by-General-Medical-Council
    Page 1 · response
    Published 20 December 2013

    Open published response

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

Back to top

Data last updated 7 September 2026