Recurring concern

Unreliable transfer of triage information for urgent clinical appointments

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First reported 24 Aug 2016•Latest report 6 Mar 2018

Definition

What this concern includes

Includes failures in the bounded triage-to-urgent-appointment information process, including transfer of triage notes, communication of urgency between triage staff, availability of triage information to the appointment clinician, and related controls needed to preserve clinically important triage information across staff handoffs.

Not included

Excludes generic referral triage failures where the concern is not transfer of triage information for an urgent clinical appointment.
Excludes emergency-department, ambulance or telephone-triage systems unless the assertion specifically concerns the same urgent clinical appointment information-transfer process.
Excludes appointment scheduling or clinical assessment failures occurring after relevant triage information and urgency have been reliably transferred.
Excludes generic communication, documentation or staffing deficiencies unless they directly impair transfer of triage information for an urgent clinical appointment.

Reports: 2
Individual concerns: 2
Date range: 2016–2018
Stated actions: 1

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.

Aneurin Bevan University LHB1

Grange Clinic1

North West Ambulance Service NHS 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.

6 Mar2018
Gwent
Concerns raised1
1. Failure to ensure continuity and availability of triage information for emergency appointment clinicians
This report raised 5 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.
Respondent positions 2
1. Position
  Direct management of service delivery and oversight of independent primary care contractor staff falls outside the Health Board’s functions.
  Stated by Aneurin Bevan University LHBOutside remit
1. Position
  Independent primary care contractors are responsible for safe service delivery, professional standards, regulatory compliance and patient accessibility.
  Stated by Aneurin Bevan University LHBRedirects responsibility
AI-generated summary

ELLIE MAY CLARK · 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

Ellie May Clark was a child with severe asthma who became seriously unwell after attending her GP surgery and was later found to have died from bronchial asthma. The report identified concerns about care planning, triage delays and systems, her being turned away from an emergency appointment without clinical assessment or safeguarding advice, the recording of her severe asthma, and staff support when challenging decisions.

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 ensure continuity and availability of triage information for emergency appointment clinicians
Wider context from the report
“(4) The lack of an effective and robust triage system. The receptionist who spoke with ████████ on the telephone and the doctor who triaged Ellie were different to the receptionist ████████ spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment. ”
Source location
ELLIE MAY CLARK · 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
Direct management of service delivery and oversight of independent primary care contractor staff falls outside the Health Board’s functions.

Verbatim wording from the response
“It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.”

Source location
2018-0066-Response-by-University-Health-Board
Page 1 · response
Published 16 June 2018
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
Independent primary care contractors are responsible for safe service delivery, professional standards, regulatory compliance and patient accessibility.

Verbatim wording from the response
“It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.”

Source location
2018-0066-Response-by-University-Health-Board
Page 1 · response
Published 16 June 2018
Open published response
24 Aug2016
Cheshire
Concerns raised1
1. Lack of an operational policy for communicating urgent doctor’s appointment needs between triage nurses
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
  Apply a procedure requiring staff to manually record attempted but unavailable appointment bookings.
  Stated by North West Ambulance Service NHS TrustStated completed
AI-generated summary

Joyce Mary Ravenhill · 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 Mary Ravenhill became ill with abdominal pain and vomiting on Christmas Day 2015, was not given an earlier out-of-hours doctor appointment after two triage assessments, and was later found to have an incarcerated femoral hernia causing intestinal obstruction. She underwent surgery but died on 2 January 2016; the principal concern was that there was no facility or operational policy to communicate the urgency of the first triage assessment to the second triage nurse.

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 an operational policy for communicating urgent doctor’s appointment needs between triage nurses
Wider context from the report
“Although a summary of the first triage assessment on 26th December 2015 was available to the second triage nurse, there was no facility / operational policy whereby the simple fact that the deceased needed an urgent doctor’s appointment could be effectively communicated by the first triage nurse to the second, all information and communication being automatically electronically generated. ”
Source location
Joyce Mary Ravenhill · 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
Apply a procedure requiring staff to manually record attempted but unavailable appointment bookings.

Verbatim wording from the response
“At NWAS a procedure has been applied for all staff to manually note where an appointment booking has been attempted, but found not to be possible.”

Source location
2016-0303-Response-by-North-West-Ambulance-Service-NHS-Trust
Page 3 · response
Published 24 August 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure continuity and availability of triage information for emergency appointment clinicians

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of an operational policy for communicating urgent doctor’s appointment needs between triage nurses

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

Respondent positions 2

Actions described in response 1