Recurring concern

Unreliable two-week-wait cancer referral pathways

First to latest report 20 Mar 2019 — 13 Mar 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
10

What this concern includes

Includes failures of the named two-week-wait cancer referral pathway and its dedicated controls, including current form availability, referral initiation and prioritisation, adherence to specialist referral advice, tracking and timely progression or completion.

What is not included
  • Excludes generic form-management failures where the forms are not part of a two-week-wait cancer referral pathway.
  • Excludes general referral, appointment or diagnostic delays that are not specifically tied to the two-week-wait cancer pathway.
  • Excludes clinical decisions not to refer where no failure to follow applicable two-week-wait pathway requirements or specialist referral advice is identified.
  • Excludes downstream cancer treatment delays that are unrelated to progression of the two-week-wait referral pathway.

Reports and published responses 4 reports

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

  1. Manchester South

    AI-generated summary

    Alan William Rowland Smith · 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

    Alan William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.

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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

    Failure to follow secondary care advice for two-week-wait dermatology referral

    Wider context from the report

    “5. In Mr Smith’s case there had been advice from secondary care to his GP that he should be referred on the 2 Week wait path for dermatology. That advice was not taken by his GP who felt such a referral was not necessary. It was unclear what if any protocol was in place across GM when such advice was given but not followed. ”

    Source location

    Alan William Rowland Smith · 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

    When secondary care considers an urgent two-week-wait referral necessary, the secondary-care clinician should complete it.

    Verbatim wording from the response

    “The standard protocol for onward referrals from secondary care (Stepping Hill Hospital) is that if a secondary care provider considers that an urgent referral onto a two week wait care pathway is required, then the referral should be completed by the secondary care clinician. This is because of the additional time involved in sending a recommendation into primary care and the referral then being completed.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 19 March 2024

    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

    GPs remain responsible for their clinical decisions when deciding whether to follow secondary-care referral advice.

    Verbatim wording from the response

    “In regard to a GP making a decision not to follow the advice of a secondary care colleague, the GP would always be responsible for their clinical decision making. It would be unusual to ignore advice from a colleague without clinical justification. In this case, my understanding is that Mr Smith was scheduled to imminently attend for a scan and the GP decision was therefore to await scan findings prior to progressing the request to process this referral. From a clinical perspective this would be appropriate and in the interest of the patient.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 19 March 2024

    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

    Awaiting the imminent scan before processing the dermatology referral was considered clinically appropriate and in the patient’s interest.

    Verbatim wording from the response

    “In regard to a GP making a decision not to follow the advice of a secondary care colleague, the GP would always be responsible for their clinical decision making. It would be unusual to ignore advice from a colleague without clinical justification. In this case, my understanding is that Mr Smith was scheduled to imminently attend for a scan and the GP decision was therefore to await scan findings prior to progressing the request to process this referral. From a clinical perspective this would be appropriate and in the interest of the patient.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 4 · response
    Published 19 March 2024

    Open published response

  2. Manchester South

    AI-generated summary

    Anthony Eric Williams · 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

    Anthony Eric Williams was diagnosed with advanced colorectal cancer after presenting with abdominal pain and later developing a bowel mass, spinal cord compression and brain spread. He died at Stamford Court on 28 April 2023. The concerns included national delays in specialist scanning, compliance with the two-week cancer pathway, and access to treatment, which were described as contributing to poorer outcomes and reduced chances of successful treatment.

    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 compliance with the two-week cancer pathway

    Wider context from the report

    “The inquest heard evidence that a national shortage of specialist scanning facilities such as was required in Mr Williams’ case meant that there were delays nationally with the diagnosis of cancers. This in turn led to delays in treatment and poorer outcomes for cancer patients as delays in diagnosis meant that the cancer would often have advanced further, and treatment was less likely to be successful. This was compounded by the fact that additional complications such as cord compression could arise whilst a scan was awaited and that the patient would be less able to cope with treatment such as chemotherapy when it ultimately started. The inquest also heard evidence that there were significant delays nationally in compliance with the two-week cancer pathway which led to poorer outcomes for patients as any delay in treatment reduced the likelihood of a successful outcome. Evidence was also heard that the delay Mr Williams faced between diagnosis and being seen for a plan to be developed was also part of a wider national picture of delay in accessing treatment and again reduced the chances of a successful treatment outcome. ”

    Source location

    Anthony Eric Williams · 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

    Publish imaging reporting turnaround-time guidance, including a three-day maximum for outpatient cancer-pathway PET-CT reporting.

    Verbatim wording from the response

    “In August 2023, NHS England published the Image report turnaround time guidance available here: NHS England » Diagnostic imaging reporting turnaround times. The guidance sets out the maximum turnaround times for referral for a number of imaging services, including position emission tomography CT scans (PET CT). The turnaround times for PET CT scans for outpatient cancer pathway diagnosis is three days.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 December 2023

    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

    Support NHS trusts to increase diagnostic reporting capacity through additional reporting radiographers, radiologist trainees, international recruitment and workforce planning tools.

    Verbatim wording from the response

    “The guidance includes caveats for sufficient availability of workforce as the numbers of reporting staff (radiologists and reporting radiographers) are not increasing in line with demand. We are supporting Trusts to increase reporting capacity by increasing the number of reporting radiographers and radiologist trainees per financial year, international recruitment initiatives and workforce demand and capacity planning tools.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 December 2023

    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

    Develop a national network of diagnostic hubs and roll out at least 100 community diagnostic centres to expand testing capacity and reduce waiting times.

    Verbatim wording from the response

    “In August 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care. The plan sets out how NHS intends to recover elective care (which includes cancer pathways) over three years with one of the ambitions including ensuring that 95% of patients who need diagnostic tests receive them within six weeks of referral. To do this, we have committed to patients having three more convenient access to diagnostic procedures and tests, by developing a network of diagnostic hubs across England. The plan is supported by a government spend of £28 billion, and this includes £2.3 billion to help increase the volume of diagnostic activity and reduce patient waiting times through the roll out of at least 100 community diagnostic centres to help clear backlogs of people waiting for tests such as MRI, ultrasound and CT scans.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 6 December 2023

    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

    Consolidate cancer waiting-time requirements into the Faster Diagnosis, 62-day referral-to-treatment and 31-day decision-to-treat standards.

    Verbatim wording from the response

    “As part of the NHS reform of cancer standards, it was announced in August 2023 that cancer targets would be consolidated into three key standards:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 6 December 2023

    Open published response

  3. Avon

    AI-generated summary

    Calogero Di Blasi · 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

    Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.

    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 of 2-week urgent cancer pathway timeframes to include investigation reporting and referring-clinician review

    Wider context from the report

    “(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians. ”

    Source location

    Calogero Di Blasi · 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

    Reformed cancer waiting-time standards by introducing the 28-day Faster Diagnosis Standard and consolidating nine reporting standards into three.

    Verbatim wording from the response

    “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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

    Recruit radiologists to fill vacancies and increase reporting capacity.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Use outsourced radiology reporting to maximise reports completed within the target timeframe.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Provide locum radiology cover and additional reporting sessions for existing radiologists.

    Verbatim wording from the response

    “Regrettably, in parallel with a number of organisations across the country, the Trust is not meeting this timeframe. The following mitigations have been put in place:”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Scope increased radiographer resource to support radiologists.

    Verbatim wording from the response

    “• The Division is undertaking a scoping exercise to increase the resource of radiographers who could support the radiologists.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Add radiology turnaround times to the divisional risk register.

    Verbatim wording from the response

    “All of the above actions will increase reporting capacity and seek to enact the recommendations from the national guidance. In addition, the Radiology team have added a risk to the risk register around turnaround times. This will ensure that this remains a priority for the Division.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    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

    Local management and implementation of national policies and procedures is assigned to NHS England and the responsible Integrated Care Board.

    Verbatim wording from the response

    “In preparing this response, Departmental officials have made enquiries with NHS England. The matters of concern you raise relate to the local management and implementation of national policies and procedures. As such, I requested NHS England liaise with the North Somerset and South Gloucestershire Integrated Care Board (ICB) responsible for University Hospitals Bristol and Weston NHS Foundation Trust.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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

    The Faster Diagnosis Standard is considered to address concerns by including diagnostic reporting and review times within the cancer waiting-time standard.

    Verbatim wording from the response

    “Since the death of Mr Di Blasi, NHS England and the Department have reformed cancer waiting time standards, following a clinically led review. This has replaced the two-week wait standard with the Faster Diagnosis Standard (FDS) for patients to get a cancer diagnosis or all-clear within 28 days of an urgent referral. The FDS moves focus away from process to deliver a clear clinical outcome – either diagnosing or ruling out cancer. This represents an improvement on the preceding 2-week wait standard, which was simply to “see a specialist” and addresses the coroners concerns, as the new standard takes into account times for reporting and reviewing diagnostic procedures. The reform also consolidated cancer standards from nine to three to reduce bureaucracy of reporting against a large number of standards.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 21 November 2023

    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

    Radiology reporting cannot consistently meet the three-day cancer-pathway timeframe because of national staffing shortages, despite mitigation measures.

    Verbatim wording from the response

    “As you heard in evidence, there is, regrettably, a national shortage of Radiologists. I therefore envisage that the Secretary of State for Health may wish to add to the below response from the Trust.”

    Source location

    Response from University Hospitals Bristol and Weston NHS Foundation Trust
    Page 2 · response
    Published 21 November 2023

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Mrs Pamela Sunter · 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

    Mrs Pamela Sunter died on 1 July 2017 in Northern General Hospital, Sheffield, after developing a rare infection that progressed to abdominal aortic aneurysms arising from aortitis. The report identified potential confusion between urgent ultrasound referrals and two-week-wait consultant appointment referrals, including the continued availability of obsolete forms on a system alongside new forms.

    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 prioritise removal of obsolete two week wait forms from the system

    Wider context from the report

    “a) The removal of the two week wait forms that are no longer to be used might be given as much priority as the placing on the system of new forms. Too many old forms on the system could lead to an unnecessary confusion. ”

    Source location

    Mrs Pamela Sunter · Prevention of Future Deaths report
    Page 2 · 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