Recurring concern

Failure to provide timely cardiology assessment

First to latest report 18 Oct 2013 — 17 Jul 2024

Reports that mention this concern
8
Times this concern has been raised
8
Stated actions linked to this concern
8

What this concern includes

Includes failures of the cardiology assessment pathway that delay or prevent timely specialist assessment, including unavailable out-of-hours in-person cardiologist assessment, prolonged waits for cardiology appointments, and failures in referral or access arrangements that directly impair cardiology assessment.

What is not included
  • Excludes cardiac treatment, surgery, intervention or procedure-capacity failures where cardiology assessment access is not the unsafe condition.
  • Excludes delays in cardiac investigations or test-result transfer unless they directly prevent or delay cardiology assessment.
  • Excludes generic medical staffing, communication or inter-organisational coordination deficiencies unless they directly impair timely cardiology assessment.
  • Excludes specialist assessment concerns outside cardiology unless the reports explicitly support the same cardiology assessment pathway.

Reports and published responses 8 reports

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

  1. Manchester South

    AI-generated summary

    Lorraine Julia Proctor · 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

    Lorraine Julia Proctor had a history of cardiac health issues and was found unresponsive at home on 22 December 2023. A post-mortem identified acute myocardial ischaemia, coronary artery atheroma and ischaemic cardiomyopathy as the direct causes of death. The report raised concerns about lengthy cardiology waiting lists delaying specialist input for patients, although it was stated that an earlier appointment was unlikely to have changed Ms Proctor’s treatment.

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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

    Delays in cardiology specialist appointments

    Wider context from the report

    “The inquest was told that there are significant backlogs for cardiology appointments not just in Greater Manchester but nationally. The reasons the inquest was told were multi factorial and included demand, resources available, covid backlogs and the impact of strike action. As a consequence patients referred for first cardiology appointments from primary care are often waiting in excess of 40 weeks for a first specialist appointment and existing cardiology patients are also waiting similar periods of time for follow up appointments. In Ms Proctor’s case the inquest was told that it was unlikely that there would have been a change to the treatment she was on even if she had been seen. However it was clear that this would not always be the case and patients requiring specialist input were not receiving it within the timescales that reduced the risk of complications and death. ”

    Source location

    Lorraine Julia Proctor · 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

    Achieve the NHS Constitutional standard that 92% of patients wait no longer than 18 weeks from referral to treatment by the end of this parliament.

    Verbatim wording from the response

    “I want to assure you that tackling waiting lists is a top priority for this government, as we work to get the NHS back on its feet. We have committed to achieving the NHS Constitutional standard that 92% of patients should no longer than 18 weeks from Referral to Treatment (RTT), by the end of this parliament.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 31 July 2024

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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

    Provide additional regional and national support and scrutiny to trusts with the largest elective-care backlogs, including Manchester University NHS Foundation Trust.

    Verbatim wording from the response

    “We recognise that it is unacceptable that some patients are waiting over 40 weeks for cardiology first appointments and too long for post treatment follow ups. NHS England (NHSE) is taking forward a programme of work to transform outpatient services, to ensure that patients can be seen more quickly and give patients more choice and flexibility about their treatment. The NHS and Department are also providing additional regional and national”

    Source location

    Response from DHSC
    Page 1 · response
    Published 31 July 2024

    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

    Work towards eliminating elective-care waits exceeding 65 weeks by September 2024, consistent with NHS England’s 2024–25 planning guidance.

    Verbatim wording from the response

    “support and scrutiny to the most challenged trusts with the largest backlogs, including Manchester University NHS Foundation Trust, and continue to work towards the target in NHSE’s 24/25 planning guidance to eliminate waits of over 65 weeks by September 2024.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 July 2024

    Open published response

  2. Manchester South

    AI-generated summary

    James Neil COCKBURN · 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 Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.

    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 patients waiting to see a cardiologist

    Wider context from the report

    “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral. The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out. In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal. ”

    Source location

    James Neil COCKBURN · 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

    Deliver the Long-Term Workforce Plan, including expanded education, training, recruitment, retention, and strategic workforce planning.

    Verbatim wording from the response

    “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 July 2024

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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

    Support local services to recover elective care, reduce waiting times, improve diagnostic turnaround, and create additional capacity for complex and urgent care.

    Verbatim wording from the response

    “In February 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care which sets out that the NHS is working to recover elective care over a three-year period. The plan includes the ambition to bring down waiting times for elective care, as well as improving diagnostic turnaround times and pathways. This includes plans to support local areas to create extra capacity within NHS services to focus on more complex areas, such as cardiac surgery, and improve the service provision for the most clinically urgent patients.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 4 July 2024

    Open published response

  3. South Yorkshire (Eastern)

    AI-generated summary

    Anne HAWKES · 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

    Anne HAWKES was admitted to Rotherham Hospital after a fall and hip fracture, and later developed fluid overload associated with poorly managed cardiac failure. Her surgical wound broke down, with delayed tissue viability referral and an incohesive approach to wound management; she died on 15 July 2023 from multi-organ dysfunction due to an infected hip joint. The stated concerns were delayed cardiology referral and poor communication between surgery, cardiology and tissue viability services.

    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 automatic cardiology referral for in-patients with known cardiac failure

    Wider context from the report

    “(1) The delayed cardiology referral whilst Mrs Hawkes was on an orthopaedic ward led to sub-optimal management of her cardiac failure which in turn is implicated in her death. There is no procedure in place at the Trust for Clinicians to automatically refer in-patients with known cardiac failure to cardiology for expert management. ”

    Source location

    Anne HAWKES · Prevention of Future Deaths report
    Page 2 · 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

    Not all inpatients with known heart failure require automatic referral; referral is indicated when decompensation or fluid overload signs occur.

    Verbatim wording from the response

    “The aforementioned process is in addition to clinicians recognising other signs and symptoms of heart failure which also prompt referral to cardiology/heart failure service. Furthermore, orthopaedic inpatients are also reviewed by an orthogeriatrician during the Friday ward round where specialist input and guidance can be sought as to the medical management of the patient.”

    Source location

    Response from The Rotherham
    Page 2 · response
    Published 4 April 2024

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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

    Automatic referral is not adopted because it would place disproportionate additional pressure on the service without benefiting patients.

    Verbatim wording from the response

    “I acknowledge that you have highlighted there is no automatic referral for in-patients with known cardiac failure. It should be acknowledged that not all patients with known heart failure mandate a referral to the Heart Failure Service, unless there are signs of decompensation (including shortness of breath, decreasing oxygen saturations and tachycardia) and/or fluid overload (visible oedema and/or changes in body weight). We have carefully considered this and concluded that automatic referral would place a disproportionate amount of additional pressure on the service which ultimately would not prove beneficial for patients.”

    Source location

    Response from The Rotherham
    Page 2 · response
    Published 4 April 2024

    Open published response

  4. Cambridgeshire and Peterborough

    AI-generated summary

    Charlotte Burton · 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

    Charlotte Burton, who was 40 and recently postpartum, returned to hospital on 27 November 2020 with shortness of breath and coughing up blood. She later deteriorated, suffered a cardiac arrest and died from acute left ventricular failure associated with cardiomyopathy, morbid obesity and pre-eclampsia. The report identified delayed recognition and treatment of likely diastolic heart failure, delayed escalation, and limited out-of-hours access to cardiology assessment as concerns.

    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 timely out-of-hours in-person cardiologist assessment for patients with suspected cardiac problems

    Wider context from the report

    “1. The evidence indicates that there is a nationwide shortage of suitably trained Cardiologists and that, particularly in District General Hospital setting, this means that out of hours there is no provision for patients presenting with suspected cardiac problems to be assessed in person by a Cardiologist. The system is therefore reliant upon doctors of different specialities or cardiac nurses recognising the condition and the need for contact with specialist at a different Trust. This still does not allow for in person assessment unless there is a transfer which is not always possible due to the severity of the condition or cannot be achieved in a suitable timescale and this represents an ongoing risk of future deaths. ”

    Source location

    Charlotte Burton · Prevention of Future Deaths report
    Page 4 · 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

    Publish the NHS Long Term Workforce Plan to expand, retain and reform the NHS workforce.

    Verbatim wording from the response

    “In June 2023, NHS England published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years to ensure that we are improving access, providing safe and timely urgent and emergency care and continuing to reduce elective care backlogs. The Plan is underpinned by the biggest recruitment drive in NHS history.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 28 November 2023

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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

    Continue delivering the Medical Specialty Distribution programme to redistribute postgraduate cardiology training places according to population need.

    Verbatim wording from the response

    “NHS England, together with the wider health system is also continuing to deliver the Medical Specialty Distribution programme; the programme was developed in light of the Facing the Facts, Shaping the Future report, published by the former Health Education England (now part of NHS England) and NHS England and a joint review of distribution of postgraduate medical training places. The Programme commenced in Autumn 2022, initially looking at three specialties, one of which is Cardiology, and will continue over the next 10-15 years. Work is in progress to ensure that the distribution of post graduate specialty training is done in a way that:”

    Source location

    Response from NHS England
    Page 1 · response
    Published 28 November 2023

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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 seven-day cardiovascular service standards requiring timely consultant review, diagnostic access, consultant-directed interventions and ongoing high-dependency review.

    Verbatim wording from the response

    “In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance compliance. This included a requirement for all cardiovascular networks to implement the four priority standards of timely consultant review, improved access to diagnostics, consultant directed interventions and ongoing review into high dependency areas across all seven days of the week. There is a good level of compliance with these standards across acute trusts and many services and surgical and diagnostic lists are operating at weekends and evenings.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 28 November 2023

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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

    Cambridgeshire and Peterborough ICB is responsible for explaining local cardiology provision, workforce arrangements and weekend transfer policy.

    Verbatim wording from the response

    “The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Cambridgeshire and Peterborough Integrated Care Board (ICB) on what system arrangements they have in place for their cardiology provision and workforce, to include transfer policy on weekends.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 28 November 2023

    Open published response

  5. Manchester South

    AI-generated summary

    Michael Kevin Amesbury · 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

    Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.

    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 cardiology clinic assessment due to insufficient clinician or appointment-slot availability

    Wider context from the report

    “2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans-oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient. ”

    Source location

    Michael Kevin Amesbury · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Margaret Ena Warwick · 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

    Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.

    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 cardiology capacity and out-of-hours cover for timely assessment

    Wider context from the report

    “1. The Inquest heard that under the NICE guidance where a patient needs an operation for a hip fracture such as in Mrs Warwick’s case and needs optimising, that optimisation should be dealt with expeditiously. In Mrs Warwick’s case she needed cardiology assessment. That delay was due in part to a shortage of cardiologists at the trust exacerbated in particular by a lack of cover by cardiologists over weekends and OOH. The Inquest heard that there was no facility for a patient such as Mrs Warwick to be assessed by cardiology over the weekend; ”

    Source location

    Margaret Ena Warwick · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    James Hadfield Withers · 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 Hadfield Withers died on 27 January 2013 after surgery for invasive colonic adenocarcinoma, with the inquest recording congestive cardiac failure associated with diseased heart and the stress of the operation. Concerns included a five-day delay in cardiology review, missing medical and nursing notes, incorrect recording of DNAR status, and poor communication among staff and with the family.

    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 requested cardiologist attendance

    Wider context from the report

    “1. There was a delay of five days between the Cardiologist being requested to see the patient and actually attending the patient. ”

    Source location

    James Hadfield Withers · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Manchester South

    AI-generated summary

    Jennifer Elsie RUSHWORTH · 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 circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.

    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 cardiology review for patients proposed for surgery

    Wider context from the report

    “The first of the issues that he raised was the fact that it is quite normal for cardiology review to take anything up to six months to come through to the surgeon proposed to operate on the patient. In this particular instance the first consultation with the surgeon took place on 5 July 2012 and in view of her cardiac history he referred her to the cardiologist for cardiac optimisation review. Report back from the cardiologist came on 28 January 2013. It seems to me unsatisfactory that this length of time should elapse for cardiology reviews in these circumstances. ”

    Source location

    Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report
    Page 1 · 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