Recurring concern

Failure to obtain timely specialist clinical advice when local expertise is insufficient

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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

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.

  1. County Durham and Darlington

    AI-generated summary

    PATRICIA LILLIAN CHAPMAN · 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

    PATRICIA LILLIAN CHAPMAN was a patient at Sedgefield Community Hospital who suffered a severe hypoglycaemic attack on 8 July 2013 and died from another hypoglycaemic attack early the following day. The inquest identified shortcomings in her care and concluded that her death was the avoidable consequence of an avoidable hypoglycaemic episode. A substantive concern was that revised policies did not address obtaining immediate emergency advice from an appropriate expert for community hospital staff.

    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 provide community hospital staff with access to emergency advice from an appropriate expert

    Wider context from the report

    “(1) The revised training and flow chart does not include any reference to staff in a community hospital being able to obtain emergency advise from an expert in the emergency department of one of the Trust’s acute hospitals (or from an expert in another department of the said hospitals if appropriate) to assist in giving immediate medical cover whilst, for example, other steps are being taken or whilst an ambulance is on route after having been summoned. It may well be the case that in urgent situations immediate medical advice from an appropriate expert might be beneficial when trying to ensure a patient's safety and this is not included in the revised Trust policies. This is something that should be given consideration to. ”

    Source location

    PATRICIA LILLIAN CHAPMAN · Prevention of Future Deaths report
    Page 1 · 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

    Introduce an operational procedure enabling community hospital staff to obtain urgent acute-hospital medical advice while awaiting an ambulance.

    Verbatim wording from the response

    “We have also introduced an operational procedure for community hospital staff who may require urgent advice whilst waiting for an ambulance to arrive, as follows:”

    Source location

    2015-0159-Response-by-County-Durham-and-Darlington-NHS-Trust
    Page 2 · response
    Published 23 April 2015

    Open published response

  2. Central and South East Kent

    AI-generated summary

    Betty 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

    Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising 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

    Failure to refer high-risk patients to a Tertiary Centre for second opinion and management

    Wider context from the report

    “• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management. ”

    Source location

    Betty SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thomas George 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

    Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

    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

    Reluctance to involve other hospital disciplines in paediatric care

    Wider context from the report

    “(3) Similarly the expert commented that there appeared to be a reluctance on the paediatric ward to bring in other disciplines from the hospital where this might be ”

    Source location

    Thomas George Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026