Recurring concern

Unreliable neurological referral pathways

First to latest report 4 Jan 2016 — 10 Feb 2020

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
3

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.

What is 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 and published responses 4 reports

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

  1. Bedfordshire and Luton

    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

  2. West Yorkshire Eastern

    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

  3. Birmingham and Solihull

    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. Plymouth, Torbay and South Devon

    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

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