Recurring concern

Unreliable Consultant-to-Consultant referral processes

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First reported 16 Nov 2015•Latest report 23 Jun 2025

Definition

What this concern includes

Includes failures in the named Consultant-to-Consultant referral process, including current guidance and its dissemination, identifying when consultant-to-consultant referral is required, initiating the referral, ensuring it reaches the appropriate specialty and ensuring consultant-level review where required.

Not included

Excludes generic referral delays or information-sharing failures that are not specifically part of the Consultant-to-Consultant referral process.
Excludes referrals to non-consultant services or unrelated specialist referral pathways unless the assertion explicitly concerns Consultant-to-Consultant referrals.
Excludes failures in the clinical assessment or treatment provided after a referral has been appropriately received and reviewed.
Excludes generic policy, training or documentation deficiencies unless they directly impair the safe operation of the Consultant-to-Consultant referral process.

Reports: 3
Individual concerns: 3
Date range: 2015–2025
Stated actions: 6

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

49 Marine Avenue Surgery1

Department of Health and Social Care1

Hywel Dda University LHB1

Maidstone and Tunbridge Wells NHS Trust1

Moorbridge1

NHS North East and North Cumbria Integrated Care Board1

Northumbria Healthcare NHS Foundation Trust1

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.

23 Jun2025
Northumberland
Concerns raised1
1. Confusion and delayed cascading of Consultant-to-Consultant referral guidance
This report raised 9 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 3
1. Action
  Discuss referral pathway learning and required actions with the North East and North Cumbria GP Provider interface group by October 2025.
  Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated planned
2. Action
  Clarify ambiguous consultant requests and notify consultants when requested actions cannot be completed, seeking further direction where necessary.
  Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progress
3. Action
  Adopt and communicate the NENC consultant-to-consultant referral policy as local Trust policy following consultation and ratification.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
AI-generated summary

REDACTED Deceased · 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

The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient 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
Confusion and delayed cascading of Consultant-to-Consultant referral guidance
Wider context from the report
“2.There was no referral to gastroenterology I am concerned there is confusion as to the guidance on Consultant-to-Consultant referrals. The Consultant Physician wrote to the GP saying, "please monitor weight loss and refer into gastroenterology services for further assessment". The GP was aware of guidance regarding Consultant-to-Consultant Referrals that had been updated in October 2023 so that Consultants could and should be directly referring patients themselves to another speciality if there was a clinical reason to do so, rather than passing that task back to the GP. The Consultant Physician told me the guidance was not cascaded down to trust level until December 2023 after the Consultant Physician saw the deceased and that the final guidance has not yet been received. ”
Source location
REDACTED Deceased · 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
Discuss referral pathway learning and required actions with the North East and North Cumbria GP Provider interface group by October 2025.

Verbatim wording from the response
“• Clarification of Referral Pathways: We are fully committed to working with our secondary care colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the North East and North Cumbria GP Provider interface group by October 2025. If new pathways are introduced, we will seek to confirm they are operational rather than assume everyone is aware. If there is any uncertainty or ambiguity regarding the request in a letter, we will write back to the Consultant to clarify. If any actions are unable to be carried out for any reason, we will write to the Consultant to inform them and ask if any further action on our part is needed.”

Source location
2025-0314 - Response from 49 Marine Avenue Surgery
Page 2 · response
Published 14 July 2025
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
Clarify ambiguous consultant requests and notify consultants when requested actions cannot be completed, seeking further direction where necessary.

Verbatim wording from the response
“• Clarification of Referral Pathways: We are fully committed to working with our secondary care colleagues to ensure that any information that is shared between primary and secondary healthcare pathways and communication is implemented as part of the learning and actions from this case. This will be discussed, for action, at the North East and North Cumbria GP Provider interface group by October 2025. If new pathways are introduced, we will seek to confirm they are operational rather than assume everyone is aware. If there is any uncertainty or ambiguity regarding the request in a letter, we will write back to the Consultant to clarify. If any actions are unable to be carried out for any reason, we will write to the Consultant to inform them and ask if any further action on our part is needed.”

Source location
2025-0314 - Response from 49 Marine Avenue Surgery
Page 2 · response
Published 14 July 2025
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
Adopt and communicate the NENC consultant-to-consultant referral policy as local Trust policy following consultation and ratification.

Verbatim wording from the response
“19. During the inquest, the Trust gave oral evidence regarding the implementation and cascading of the new consultant to consultant referral guidance. The Trust has adopted the Northeast North Cumbria (NENC) Consultant team to Consultant team referral policy via the Northumberland and North Tyneside GP/Provider interface group organised via NENC ICB. This will be adopted as a local policy and communicated to all clinicians within Northumbria by the Trust Policy group on behalf of the Executive Medical Director by the end of October 2025, following consultation/ratification at the Trust’s CPG (Clinical Policy Group). Primary Care colleagues also have access to the Trust’s Advice and Guidance service across the acute secondary care specialties to request advice and guidance on clinical cases, in this case including Gastroenterology.”

Source location
2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Page 4 · response
Published 14 July 2025
Open published response
27 Jul2016
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Failure to ensure that consultant referrals are seen by consultants in the first instance
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.
Actions described in response 2
1. Action
  Ask consultants to review referral practice and ensure consultant review, appropriate delegation and supervision.
  Stated by Hywel Dda University LHBStated completed
2. Action
  Develop a process to provide specialist advice through an alternative on-site or cross-site specialist when a single-handed consultant is absent.
  Stated by Hywel Dda University LHBStated in progress
AI-generated summary

Cerith Wyn Pugh · 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

Cerith Wyn Pugh underwent surgery for bowel obstruction in March 2013, experienced a cardiac arrest and further surgery, and had subsequent hospital readmissions. He died on 20 May 2014 after developing bleeding from his ileostomy; the inquest recorded multi-organ failure, ischaemic bowel disease, and cholelithiasis with mechanical jaundice. Concerns included consultant referrals being handled initially by middle grade doctors and liver function tests being declined because testing had been conducted less than three days earlier, without evidence of a mechanism to override that guidance when clinically appropriate.

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 consultant referrals are seen by consultants in the first instance
Wider context from the report
“That referrals to consultants at Withybush General Hospital are routinely being dealt with by middle grade doctors and, if in the opinion of the middle grade doctor, the matter then needs a referral to a consultant only then is the matter passed to a consultant. All consultant referrals should be seen by consultants in the first instance. Expert evidence received at the inquest described this practice as not being best practice. ”
Source location
Cerith Wyn Pugh · 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
Ask consultants to review referral practice and ensure consultant review, appropriate delegation and supervision.

Verbatim wording from the response
“Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concerns we have issued your redacted report to the Hospital Directors (lead doctors) in each of the four acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on a particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by an alternative consultant on site, or a similar specialist on a different site.”

Source location
2016-0271-Response-by-University-health-Board
Page 1 · response
Published 27 July 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 process to provide specialist advice through an alternative on-site or cross-site specialist when a single-handed consultant is absent.

Verbatim wording from the response
“Thank you for your report into the death of Cerith Wyn Pugh. As a result of your concerns we have issued your redacted report to the Hospital Directors (lead doctors) in each of the four acute hospitals and through them we have asked each consultant to review their practice and to ensure that consultant referrals are directly reviewed by the consultant or that the review involves proactive delegation where appropriate, and consultant supervision. Some of our services are led by a single handed consultant on a particular site and this does provide some challenges when this individual is on leave. We are actively looking at the process we need to put in place in these cases so that specialist advice can always be accessed either by an alternative consultant on site, or a similar specialist on a different site.”

Source location
2016-0271-Response-by-University-health-Board
Page 1 · response
Published 27 July 2016
Open published response
16 Nov2015
Mid Kent and Medway
Concerns raised1
1. Restriction of out-of-hours radiography referrals to consultant-to-consultant referral
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.
Actions described in response 1
1. Action
  Require consultant-to-consultant referrals for out-of-hours radiology to ensure consultant involvement in treatment decisions.
  Stated by Maidstone and Tunbridge Wells NHS TrustStated completed
Respondent positions 1
1. Position
  The consultant-to-consultant out-of-hours radiology referral policy is considered clinically justified and ensures adequate consideration of treatment options.
  Stated by Maidstone and Tunbridge Wells NHS TrustExisting arrangements considered sufficient
AI-generated summary

Christine McNamara · 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

Christine McNamara was admitted for an elective ERCP, developed symptoms of bowel perforation, deteriorated despite treatment and died at Maidstone Hospital on 27 February 2015. The concerns identified were the absence of a pathway or guideline for post-ERCP complications and limitations on out-of-hours radiography referrals and surgical consultant cover.

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
Restriction of out-of-hours radiography referrals to consultant-to-consultant referral
Wider context from the report
“(2)Out of hours radiography can only be referred on a consultant to consultant basis. There is no surgical consultant on call from Maidstone during the working week although there is a surgical consultant at Tunbridge Wells ”
Source location
Christine McNamara · Prevention of Future Deaths report
Page 1 · 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
Require consultant-to-consultant referrals for out-of-hours radiology to ensure consultant involvement in treatment decisions.

Verbatim wording from the response
“Out of hours, junior doctors manage the immediate treatment of patients – escalating patients for additional investigations and/or procedures where necessary. In the past we have had instances where junior doctors were escalating the treatment of unwell/seriously unwell patients without consultant input. This resulted in consultants not being adequately involved in the treatment decisions of their patients, so to resolve this we introduced the consultant to consultant referral – thereby ensuring there is always adequate consideration of all treatment options.”

Source location
2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 16 November 2015
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
The consultant-to-consultant out-of-hours radiology referral policy is considered clinically justified and ensures adequate consideration of treatment options.

Verbatim wording from the response
“I appreciate that, taken out of context, the need for a consultant to consultant referral for radiology out of hours can seem onerous, but I want to assure you that there are sound clinical reasons underlying the policy.”

Source location
2015-0436-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 2 · response
Published 16 November 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Confusion and delayed cascading of Consultant-to-Consultant referral guidance

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

Concerns raised1

Failure to ensure that consultant referrals are seen by consultants in the first instance

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.2

Concerns raised1

Restriction of out-of-hours radiography referrals to consultant-to-consultant referral

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Actions described in response 2

Actions described in response 1

Respondent positions 1