First reported 9 Jul 2014•Latest report 6 May 2026
Definition
What this concern includes
Includes failures in arrangements for recognising the need for, requesting, accessing, communicating or acting on specialist clinical advice from another hospital or specialist centre when local expertise is insufficient or the patient's condition requires specialist input.
Not included
Excludes generic clinical delays, referrals or communication failures where specialist advice is not the identified unsafe condition.
Excludes failures limited to obtaining routine specialist appointments or treatment after appropriate specialist advice has already been obtained.
Excludes deficiencies in specialist expertise or treatment quality where the access and advice process itself is not deficient.
Excludes failures belonging to a separately named specialist pathway or condition-specific referral system when that narrower boundary is the supported recurring concern.
Reports
13
Distinct published reports
Individual concerns
15
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
18
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.
Care Quality Commission2
Cwm Taf Morgannwg University Local Health Board2
Blackpool Teaching Hospitals NHS Foundation Trust1
Cardiff & Vale University LHB1
County Durham and Darlington NHS Foundation Trust1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
Epsom Hospital1
Leeds Teaching Hospitals NHS Trust1
Manchester University NHS Foundation Trust1
National Institute for Health and Care Excellence1
NHS England1
NHS South West London Integrated Care Board1
Pennine Acute Hospitals NHS Trust1
Prince Charles Hospital (Merthyr Tydfil)1
NHS trust9
Healthcare site4
Executive non-departmental public body2
Health and social care service regulator2
Health professional body2
Local health board2
Devolved government1
Integrated care board1
Ministerial department1
Professional body1
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.
South Wales Central
Concerns raised2
Lack of an established protocol for escalation and referral of HPB-related matters to a tertiary centre
Delays in seeking specialist advice and transferring patients to a tertiary centre
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.8
Action
Require early consultant-to-consultant referral to the University Hospital of Wales HPB team for specialist advice and transfer decisions.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Share lessons from the case with other health boards to inform their inter-hospital pathway arrangements.
Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Reinforce the expectation of early consultant-level discussion for suspected bile duct injury and complex benign HPB cases.
Stated by The Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Remind relevant partners to use the existing HPB escalation framework, designated contacts and urgent advice procedures, and consider timely transfer.
Stated by The Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Action
Use focused communication and education to reinforce referral and escalation principles for suspected bile duct injury.
Stated by The Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 July 2026.
Action
Develop and disseminate a formal regional escalation and referral framework specifying triggers, discussion timescales, contacts and transfer expectations.
Stated by The Health BoardStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Embed learning through clinical governance, oversee implementation of revised escalation arrangements, confirm communication, and test compliance through audit or case review.
Stated by The Health BoardStated plannedThe respondent said that this action was planned when they made their response on 10 July 2026.
Action
Transfer indicated patients promptly to the University Hospital of Wales HPB team and coordinate timely acceptance while avoiding unnecessary delays.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing health board actions to improve clinical understanding, referral and inter-hospital transfer arrangements are considered appropriate and proportionate to resolve the concerns.
Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Established clinical standards provide guidance; the principal failure was inconsistent application, not absence of specialist knowledge or access.
Stated by The Health BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Yorkshire and York
Concerns raised1
Failure to seek specialist input from the Leeds treating 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.
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
Action
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Contact York surgical colleagues to explain communication arrangements and discuss measures to prevent similar coordination failures.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Inner West London
Concerns raised1
Unsafe access pathway requiring physically frail QMH patients to travel by LAS ambulance to SGH A&E for psychiatric advice
This report raised 4 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.
Manchester South
Concerns raised1
Failure to obtain and follow up further haematology advice when INR remains above target
This report raised 3 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing 24-hour haematology support, anticoagulation guidance and ward-team responsibilities provide arrangements for INR management and follow-up.
Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Herefordshire
Concerns raised1
Failure to consult the overseeing hospital’s relevant specialist department when admitted patients have conditions overseen by another hospital
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Operate divisional standard operating procedures requiring named local consultants and consultation with relevant specialist departments at the overseeing hospital.
Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
Manchester North
Concerns raised1
Delays in obtaining specialist-centre advice despite lack of local expertise
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.
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
Action
Remind trainees to refer patients urgently to endocrinology when Cushing’s disease is suspected or diagnosed.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The response disputes that referral to Salford Royal was delayed, stating that diagnostic testing was necessary before specialist referral.
Stated by Northern Care Alliance NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised2
Failure to obtain appropriate specialist assistance for hyponatraemia management
Failure to complete specialist consultation for hyponatraemia management
This report raised 8 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Classify desmopressin as a high-risk drug requiring specialist advice before discontinuation and a plan for reintroduction.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2018.
Blackpool and the Fylde
Concerns raised1
Failure to obtain requisite specialist advice for unfamiliar conditions
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Appoint a consultant physician with specific expertise in managing Parkinson’s disease.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2018.
Action
Issue an internal alert reminding staff about timely Parkinson’s disease management, specialist referral and access to the procedure on the Trust intranet.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing Parkinson’s disease procedure and specialist contact arrangements provide sufficient access to timely advice and assistance when required.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner South London
Concerns raised1
Failure to escalate children with jaundice to suitable specialist care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Lack of on-site specialist clinical support for complications
This report raised 14 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Review alternative pathways and external oversight for PEG placement, including competency-based training and accreditation.
Stated by Queen Victoria Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
Action
Progress the BSUH partnership memorandum and develop robust documentation or an SLA for specialist services.
Stated by Queen Victoria Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
QVH disputes that its lack of on-site specialists prevents access to specialist opinion, because agreements with BSUH provide specialist advice and imaging.
Stated by Queen Victoria Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The service-level agreement provides immediate access to general surgical advice, so specialist expertise is available despite no general surgeon on site.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures in arrangements for recognising the need for, requesting, accessing, communicating or acting on specialist clinical advice from another hospital or specialist centre when local expertise is insufficient or the patient's condition requires specialist input.
