Recurring concern

Failure to reliably refer patients to required specialist services

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First reported 19 Jan 2014•Latest report 4 Feb 2026

Definition

What this concern includes

Includes failures in making, recording, tracking or completing clinically required referrals to specialist services, including physiotherapy, occupational therapy, dietetics and specialist nursing, where the referral is needed for assessment, rehabilitation, treatment or safe care.

Not included

Excludes referral delays or omissions involving a named pathway or service with a more specific established recurring concern, such as mental-health, social-care or district-nursing referrals.
Excludes failures in specialist assessment or treatment after a referral has been reliably completed and accepted.
Excludes generic communication, staffing, documentation or care-planning deficiencies unless they directly cause failure to complete a required specialist referral.
Excludes requests for general advice or informal consultation where no required referral to a specialist service is identified.

Reports: 35
Individual concerns: 38
Date range: 2014–2026
Stated actions: 65

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.

NHS England4

Department of Health and Social Care3

Care Quality Commission2

Hc-One Limited2

Manchester University NHS Foundation Trust2

NHS Greater Manchester Integrated Care Board2

Adferiad Recovery1

Barts Health NHS Trust1

Bedfordshire Hospitals NHS Foundation Trust1

Belong Limited1

Betsi Cadwaladr University LHB1

Bristol NHS Foundation Trust1

Brunswick Ward at Lindridge1

Castlehill Specialist Care Centre1

Cornerstone Family Practice1

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.

6 Dec2016
Manchester West
Concerns raised1
1. Lack of written guidance for referrals to outside agencies such as SALT
This report raised 1 other concern. 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
  Hold a meeting with registered managers to review policies, procedures and guidance and discuss safer care delivery.
  Stated by BelongStated planned
2. Action
  Reinforce support workers’ procedures for seeking external advice and escalating health concerns through training, induction, supervision, life-plan review and audit.
  Stated by BelongStated completed
Respondent positions 1
1. Position
  Written guidance for referrals to Speech and Language Therapy already existed in nutrition and hydration policies and supporting referral documentation.
  Stated by BelongDisputes the concern
AI-generated summary

Joyce Crompton · 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

Joyce Crompton was found unresponsive on 26 January 2016 after eating, with food in her mouth and nearby, following two earlier witnessed choking incidents. Concerns were raised that referrals to the Speech and Language Therapy team were not made after those incidents and that Belong Village lacked written guidance, systematic checks, and refresher training for such referrals.

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 written guidance for referrals to outside agencies such as SALT
Wider context from the report
“i. It is clear that although there is verbal training given on referrals to outside agencies, such as SALT, there is no written guidance that can be easily referred to when incidents arise. There is also no refresher training on the policies. Due to this there may be another occasion in the future when a referral to the SALT team is missed which could result in a future death. ”
Source location
Joyce Crompton · 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
Hold a meeting with registered managers to review policies, procedures and guidance and discuss safer care delivery.

Verbatim wording from the response
“• A meeting is being held on Wednesday, 21 December with all Belong Registered Managers to review the Policies, Procedures and Guidance and discuss how we can be more effective in our delivery of safe care.”

Source location
2016-0434-Response-by-Belong
Page 2 · response
Published 12 February 2017
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
Reinforce support workers’ procedures for seeking external advice and escalating health concerns through training, induction, supervision, life-plan review and audit.

Verbatim wording from the response
“• All Support Workers have been reminded of the correct procedures to follow and how to seek advice from outside professionals and when they need to escalate health concerns. This is incorporated into the care practice training for all staff, to include staff induction, supervision, life plan review and audit.”

Source location
2016-0434-Response-by-Belong
Page 2 · response
Published 12 February 2017
Open published response
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
Written guidance for referrals to Speech and Language Therapy already existed in nutrition and hydration policies and supporting referral documentation.

Verbatim wording from the response
“i. No written Guidance regarding referrals to outside agencies such as SALT”

Source location
2016-0434-Response-by-Belong
Page 1 · response
Published 12 February 2017
Open published response
28 Oct2016
Brighton and Hove
Concerns raised1
1. Delays in physiotherapy referral
This report raised 17 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

Leslie Isaac LERNER · 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

Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

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 physiotherapy referral
Wider context from the report
“16th May 2016 (1) Having been admitted to a renal ward, because of lack of beds elsewhere, a member of the medical staff had a telephone discussion with a member of the Orthopaedic Team and a collar and cuff sling was recommended. This information was not passed onto the Nursing Staff, not properly documented nor was the Patient actually seen by a member of Orthopaedic Team. He should have been seen and a note should have been made. (2) He then was moved to another ward, again not an Orthopaedic Ward, where any chance of correct hand over seems to have been lost because he was transferred to Baily Ward in the middle of the night. No proper handover. There was no referral to physiotherapists and yet the Trusts own paperwork says that exercises should be given by a Physiotherapist and commenced by the patient after seventy two hours of the fracture occurring. No speedy referral to physiotherapists. Within his notes was an utterly inadequate document explaining what the Patient needs to do with a fractured shoulder, however, as the Ward Manager pointed out it does not say what type of sling should be applied for this particular Patient and so she apparently had no idea anything was amiss. This document was not fit for purpose either for the patient or the ward. ”
Source location
Leslie Isaac LERNER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Oct2015
County Durham and Darlington
Concerns raised1
1. Failure to dispatch secondary care referral letters
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 1
1. Action
  Issue referral guidance requiring the referring doctor to complete and monitor referrals, retain responsibility, and avoid delegating urgent referrals.
  Stated by Spectrum Community Health C.I.C.Stated completed
AI-generated summary

James Bewick 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

James Bewick Graham, who had peripheral vascular disease and recurring problems with his left foot, was admitted to hospital after his condition deteriorated, underwent an amputation, and died on 2 November 2014. The report identified concerns about delayed referral to secondary care, poor communication between healthcare professionals, unclear responsibility for making the referral, and administrative failures that meant the referral was not dispatched.

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 dispatch secondary care referral letters
Wider context from the report
“(3) The GP who agreed to make a referral to secondary care gave evidence that she had wrote out a letter of referral and handed it to a member of the administrative team for typing and gave verbal instructions that this needed to be dealt with quickly and that if there were any problems she was to be contacted. For an unknown reason the letter of referral was not dispatched. Some consideration has been given to this issue following the publication of the PPO report but in the light of the evidence given in court the thoroughness and robustness of that letter of direction, particularly bearing in mind there have been a number of changes to the providers of healthcare in the prison, should be considered. ”
Source location
James Bewick Graham · 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
Issue referral guidance requiring the referring doctor to complete and monitor referrals, retain responsibility, and avoid delegating urgent referrals.

Verbatim wording from the response
“A Directive has been issued by Spectrum Community Health CIC, that states;”

Source location
James-Graham-Response
Page 5 · response
Published 17 December 2015
Open published response
24 Sep2014
Sunderland
Concerns raised1
1. Delays in referral to the foot protection team
This report raised 9 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

Leonard Henry Hudson · 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

Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

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 referral to the foot protection team
Wider context from the report
“During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”
Source location
Leonard Henry Hudson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jan2014
Inner North London
Concerns raised1
1. Failure to refer patients to critical care when appropriate
This report raised 1 other concern. 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 4
1. Action
  Develop formal guidelines specifying when the Critical Care Outreach Team should request critical-care medical review.
  Stated by Barts Health NHS TrustStated planned
2. Action
  Launch an education strategy and incorporate deteriorating-patient recognition and response into medical and nursing induction.
  Stated by Barts Health NHS TrustStated planned
3. Action
  Conduct an all-site cardiac-arrest call audit examining pre-arrest factors and care provided before arrests.
  Stated by Barts Health NHS TrustStated planned
1. Action
  Disseminate cardiac-arrest audit findings, agree action plans and involve relevant groups in delivering recommendations.
  Stated by Barts Health NHS TrustStated planned
AI-generated summary

Gregg O’REILLY · 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

Gregg O’Reilly was admitted as an emergency with dehydration, poor nutritional state, high stoma output, acute kidney injury and a high white cell count. He later developed multi-organ failure and repeated bleeding from his abdominal wound, but did not recover after surgery and critical care admission. The report raised concerns that he was not referred to critical care by 17.01.14 and that no observation records could be found between midnight and 3am before his second bleed and cardiac arrest call.

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 refer patients to critical care when appropriate
Wider context from the report
“I heard that an opportunity was missed by the medical, ward nursing and critical care nursing outreach teams, to refer Mr O’Reilly to critical care, certainly by 17.01.14. It is unclear whether that would have changed the outcome for him, but it meant that he was not offered optimal care. Given the number of staff who could have made such a referral, it seems that this issue goes further than individual error or lack of understanding. I appreciate that also makes it a big issue to tackle. ”
Source location
Gregg O’REILLY · 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 formal guidelines specifying when the Critical Care Outreach Team should request critical-care medical review.

Verbatim wording from the response
“5. The Critical Care Outreach Team (CCOT) and the consultant intensivists to develop formal guidelines, outlining when CCOT should request a critical care medical review.”

Source location
2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014
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
Launch an education strategy and incorporate deteriorating-patient recognition and response into medical and nursing induction.

Verbatim wording from the response
“10. Launch an Education Strategy to ensure all staff can identify a sick and deteriorating patient and can escalate concerns. The Trust medical and nursing Induction Programmes to incorporate a briefing on ‘Recognising and Responding to the Deteriorating Patient.’”

Source location
2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014
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
Conduct an all-site cardiac-arrest call audit examining pre-arrest factors and care provided before arrests.

Verbatim wording from the response
“11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.”

Source location
2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014
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
Disseminate cardiac-arrest audit findings, agree action plans and involve relevant groups in delivering recommendations.

Verbatim wording from the response
“11. The Trust is planning an "all site" Cardiac Arrest Call Audit in July 2014 to determine what factors pre-empted the call and to look at whether appropriate care was taking place prior to the arrest. Ensure the findings are widely disseminated, action plans agreed, and all key groups mentioned above are involved in delivering the key recommendations.”

Source location
2014-0221-Response-by-Barts-Health-NHS-Trust
Page 2 · response
Published 19 May 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of written guidance for referrals to outside agencies such as SALT

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Delays in physiotherapy referral

Concerns raised1

Failure to dispatch secondary care referral letters

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

Concerns raised1

Delays in referral to the foot protection team

Concerns raised1

Failure to refer patients to critical care when appropriate

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.4

Actions described in response 2

Respondent positions 1

Actions described in response 1

Actions described in response 4