Recurring concern

Delays in progressing time-critical surgical treatment

First to latest report 4 Dec 2013 — 5 Jun 2025

Reports that mention this concern
13
Times this concern has been raised
14
Stated actions linked to this concern
27

What this concern includes

Includes delays or unreliable progression at any dedicated point in the surgical treatment pathway, including readiness assessment, prioritisation, theatre access, reassessment, referral or transfer, where the reports support that the treatment should have proceeded within a clinically important timeframe.

What is not included
  • Excludes delays in non-surgical treatment or general healthcare referrals that are not part of a surgical treatment pathway.
  • Excludes generic staffing, capacity, communication or documentation deficiencies unless they are specifically tied to delayed progression of surgical treatment.
  • Excludes failures concerning the safety or quality of surgery after it has commenced, rather than timely progression to surgery.

Reports and published responses 13 reports

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

  1. West Yorkshire (Western)

    AI-generated summary

    June Elsie Parkes · 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

    June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

    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 urgent or emergency surgery for upper GI bleeds out of hours

    Wider context from the report

    “(3) There is presently no provision at Calderdale Royal Hospital to undertake urgent/emergency surgery if deemed necessary, for patients with upper GI bleeds at Calderdale Royal Hospital “out of hours” . The comments made in the final paragraph of B also applies to this point. ”

    Source location

    June Elsie Parkes · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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 prepare a patient for urgently needed surgery

    Wider context from the report

    “(8) Failure to prepare Mr. Palmer for surgery which it had been acknowledged he needed urgently. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. North and West Cumbria

    AI-generated summary

    Keith Thomas Graham · 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

    Keith Thomas Graham was involved in a road traffic collision after colliding with a bullock while travelling by motorcycle and later died from multiple injuries on 28 May 2012. Concerns included the timing of summoning on-call clinicians, the use of CT scanning for seriously injured trauma patients, and the time between presentation and theatre, as well as a misplaced chest drain that damaged the liver.

    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 between presentation and theatre when surgery is indicated

    Wider context from the report

    “To review the procedures to deal with seriously injured trauma patients on arrival at A & E to include the timing of the summons to the on call Clinicians, the contra-indications for the use of CT Scanning, and where surgery is indicated, minimising the time between presentation and theatre. ”

    Source location

    Keith Thomas Graham · 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