Recurring concern

Unreliable referrals to district nursing services

First to latest report 9 Jun 2014 — 21 May 2025

Reports that mention this concern
11
Times this concern has been raised
14
Stated actions linked to this concern
24

What this concern includes

Includes failures of the district nursing referral process that prevent or delay appropriate referral, including failure to initiate, accurately communicate, transmit, accept, direct or action referrals.

What is not included
  • Excludes generic district nursing staffing, monitoring, communication or care-quality deficiencies not specifically tied to the referral process.
  • Excludes referrals to services other than district nursing unless the assertion directly concerns a district nursing referral.
  • Excludes failures occurring solely after a valid referral has been accepted, such as the quality of subsequent nursing treatment.

Reports and published responses 11 reports

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

  1. Manchester West

    AI-generated summary

    Daniel Joseph McCallum Keane · 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

    Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.

    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 respond to an urgent clinical alert about unsafe self-management of insulin

    Wider context from the report

    “████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010. ████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action. At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision. 2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged. 3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010. 4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients in the community. ”

    Source location

    Daniel Joseph McCallum Keane · Prevention of Future Deaths report
    Page 3 · 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

    Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.

    Verbatim wording from the response

    “I consider that the first three concerns, relating to ████████ should be raised with the General Medical Council (GMC) and the Care Quality Commission (CQC). To this end, my officials contacted your office on 12 June to advise that these actions would be most appropriately addressed by the GMC and CQC. We suggested that you write to both of these organisations for their separate responses to these issues. These organisations have the power to take action where warranted.”

    Source location

    2014-0260-Response-by-Department-of-Health
    Page 2 · response
    Published 9 June 2014

    Open published response

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