Recurring concern

Unreliable neurological referral pathways

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First reported 4 Jan 2016•Latest report 10 Feb 2020

Definition

What this concern includes

Includes failures in neurological referral pathways involving referral criteria, initiation, routing, communication, escalation, tracking or timely access to neurological specialist opinion, including referrals from outlying hospitals.

Not included

Excludes referrals to non-neurological specialties unless the assertion explicitly concerns the same neurological referral pathway.
Excludes failures limited to neurological diagnosis, investigation or treatment after appropriate neurological referral or consultation has been obtained.
Excludes the existing narrower concern about neurosurgical referral systems when the assertion is specifically bounded to neurosurgery rather than neurological referrals more generally.
Excludes generic training, communication or staffing deficiencies unless they directly impair the neurological referral pathway.

Reports: 4
Individual concerns: 4
Date range: 2016–2020
Stated actions: 3

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.

Bedfordshire Hospitals NHS Foundation Trust1

Calderdale and Huddersfield NHS Foundation Trust1

Derriford Hospital1

Leeds Teaching Hospitals NHS Trust1

The Borchardt Medical Centre1

the Dudley Group NHS Foundation Trust1

University Hospitals Birmingham NHS Foundation Trust1

University Hospitals Plymouth NHS 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.

10 Feb2020
Bedfordshire and Luton
Concerns raised1
1. Delays in obtaining Neurological opinion alongside relevant imaging
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sarah YOUNG · 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

Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

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 obtaining Neurological opinion alongside relevant imaging
Wider context from the report
“(2) Although the Neurosurgical Team had advised the Bedford Emergency Department Team at 19.45 hours on 9 April 2019 that a Neurological opinion should be sought alongside the CT venogram, such opinion was not sought until 16.15 hours on 10 April 2019 (the following day) and, even then, only after further prompting from the Neurosurgical Team. The Inquest heard that a Neurological opinion was likely to have involved immediate consultation with the on-call Neuroradiologist which would have resulted in a much earlier diagnosis and treatment of the Cerebral Venous Sinus Thrombosis; ”
Source location
Sarah YOUNG · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Oct2019
West Yorkshire Eastern
Concerns raised1
1. Lack of a prescribed direct-access pathway to neuroradiology specialists
This report raised 8 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sharon Jamela Reeve · 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

Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

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 prescribed direct-access pathway to neuroradiology specialists
Wider context from the report
“(1) The two consultant radiologists at the district general hospital saw a need for a specialist opinion to assist in the interpretation of complex and abnormal CT and MRI scans. There was no clear prescribed pathway for them to obtain direct access to neuroradiologists at the tertiary centre. In consequence, an inapposite referral was made to a neurosurgical unit, which did not assist the resolution of the uncertainties regarding the correct diagnosis. My concern is that if much needed linkages between relevant groups are not appreciated and made effective, then the value of having a specialist resource could be lost in future cases, not only in the medical specialty and hospital involved here, but in many others as well. ”
Source location
Sharon Jamela Reeve · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Oct2016
Birmingham and Solihull
Concerns raised1
1. Insufficient guidance and education on neurological referrals in outlying hospitals
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
  Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
  Stated by the Dudley Group NHS Foundation TrustStated completed
2. Action
  Deliver the agreed cross-Trust action plan to address identified safety concerns.
  Stated by the Dudley Group NHS Foundation TrustStated in progress
AI-generated summary

Alfie Rose · 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

Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided his death.

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
Insufficient guidance and education on neurological referrals in outlying hospitals
Wider context from the report
“2. Education. It is important the clinicians in outlying hospitals understand how neurological referrals should be made and when. Better guidance and education is needed for outlying hospitals. ”
Source location
Alfie Rose · 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 and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.

Verbatim wording from the response
“Issues Identified:”

Source location
2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Page 2 · response
Published 26 October 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
Deliver the agreed cross-Trust action plan to address identified safety concerns.

Verbatim wording from the response
“A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT. We have commenced on the delivery of these actions and recorded our progress on the action plan for you information.”

Source location
2016-0382-Response-by-The-Dudley-Group-NHS-Trust
Page 2 · response
Published 26 October 2016
Open published response
4 Jan2016
Plymouth, Torbay and South Devon
Concerns raised1
1. Failure to apply updated Neurology referral criteria for reported weakness
This report raised 3 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
  Review current guidance for suspected brain tumours, including national and local referral, headache-management and urgent-cancer guidance, at a clinical meeting.
  Stated by Borchardt Medical CentreStated completed
AI-generated summary

Thomas Alexander Burchell · 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

Thomas Alexander Burchell had a brain tumour and developed progressive seizures after transfer for neurosurgical treatment; the post-mortem medical cause of death was brain swelling and infarction associated with glioblastoma. Concerns included incomplete records of the seizures and inadequate documentation and assessment of earlier headaches and weakness, including delays in processing prior medical records and uncertainty about referral guidance.

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 apply updated Neurology referral criteria for reported weakness
Wider context from the report
“(3) In his preparation for a subsequent significant events meeting, ████████ identified that the basis for referring a patient to Neurology had changed. He had previously been under the impression that he needed not only to have a complaint of weakness but also objectively to identify and confirm this weakness. He accepted that the guidance had changed so that a complaint of weakness alone was sufficient to warrant referral. ”
Source location
Thomas Alexander Burchell · 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
Review current guidance for suspected brain tumours, including national and local referral, headache-management and urgent-cancer guidance, at a clinical meeting.

Verbatim wording from the response
“With regard to the third concern, I took the opportunity to call a clinical meeting on 22 January. We have clinical meetings towards the end of every month and I used this meeting to review current guidance for suspected brain tumours.”

Source location
2016-0002-Response-by-The-Borchardt-Medical-centre
Page 1 · response
Published 4 January 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in obtaining Neurological opinion alongside relevant imaging

Concerns raised1

Lack of a prescribed direct-access pathway to neuroradiology specialists

Concerns raised1

Insufficient guidance and education on neurological referrals in outlying hospitals

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

Failure to apply updated Neurology referral criteria for reported weakness

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

Actions described in response 2

Actions described in response 1