Recurring concern

Delays in progressing time-critical surgical treatment

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First reported 4 Dec 2013•Latest report 5 Jun 2025

Definition

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.

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
13

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
27

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Surrey and Sussex Healthcare NHS Trust3
NHS England2
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Calderdale Royal Hospital1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Kent Hospitals University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Mid and South Essex NHS Foundation Trust1
North Cumbria Integrated Care NHS Foundation Trust1
Royal Sussex County Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
University Hospitals Sussex 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.

  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
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Data last updated 7 September 2026