Recurring concern

Unreliable operation of inter-provider healthcare service agreements

First to latest report 1 May 2015 — 22 Nov 2022

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
6

What this concern includes

Includes failures in the operation of an explicitly identified healthcare service-level agreement or equivalent inter-provider service agreement, including development and implementation of delivery plans, clarification or renegotiation of responsibilities, required governance review, communication arrangements and monitoring of agreement performance where these affect coordinated patient care.

What is not included
  • Excludes generic inter-agency communication, coordination or accountability failures where no healthcare service-level agreement or equivalent formal inter-provider agreement is identified.
  • Excludes failures in the substantive clinical care or treatment provided after the agreement has operated reliably.
  • Excludes ordinary contract-management or procurement issues with no identified patient-safety or coordinated-care consequence.
  • Excludes failures confined to a single provider's internal policy, care plan or staffing arrangement where no formal inter-provider agreement is the deficient control.

Reports and published responses 5 reports

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

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Anthony James REEDMAN · 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 James Reedman suffered a basilar artery stroke while at home, but an ambulance delay meant thrombolysis was administered 4.5 hours after the stroke. He died following a further brain haemorrhage after the unsuccessful thrombolysis attempt. The principal concerns were the lack of a 24/7 thrombectomy service for Royal Cornwall Hospital Trust patients and the absence of a service level agreement with the nearest 24/7 service when the local service was unavailable.

    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 a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable

    Wider context from the report

    “(2) The nearest 24/7 thrombectomy service is at NHS North Bristol. However, there is no service level agreement between Southmead and RCHT for the treatment of patients from Cornwall when the UHP service is unavailable. This limits the options available to RCHT clinicians in considering treatment for stroke patients. ”

    Source location

    Anthony James REEDMAN · 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

    Explore with University Hospitals Plymouth and Royal Cornwall Hospital what interim out-of-region thrombectomy referral support North Bristol can offer.

    Verbatim wording from the response

    “On an interim basis, as University Hospitals Plymouth transition to a 24/7 seven days a week thrombectomy service in October 2023, we will explore with them and RCHT what support North Bristol can offer by way of out of region referrals in an attempt to mitigate the risk of patients that are suitable for thrombectomy procedures not receiving this procedure.”

    Source location

    Response from North Bristol NHS Trust
    Page 2 · response
    Published 25 November 2022

    Open published response

  2. West Sussex

    AI-generated summary

    Stephen WELLS · 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

    Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.

    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 progress in reviewing or renegotiating the inter-Trust Service Level Agreement

    Wider context from the report

    “b) I also heard evidence from SASH that they would not have expected Mr Wells to be transferred back to them after the liver surgery as further chemotherapy was needed. Conversely, RSFT were unable to explain why Mr Wells did not remain on the Somerset Cancer Registry (SCR) tracking system following discharge and the MDT discussion on 10 August 2020. I was told that the safety net to avoid a cancer patient such as Mr Wells failing to receive further treatment is an inter-provider transfer (IPT) to ensure the responsibility for care is further transferred. In this case, a local process of consultant-to- consultant referrals, in other words a workaround, had evolved and both the hardcopy letter between doctors and an email from the CNS to two separate doctor’s secretaries had failed resulting in no further appointment being made. It was accepted that the communication failure was not identified in a timely manner and that communication systems between both Trusts had blurred with the suggestion that these could be clarified by a renegotiation of the Service Level Agreement (SLA). I was provided with a copy of the current SLA dated 1 January 2015 and note that the particulars state the contract term was 36 months with an end date of 31 December 2017. Given the importance of good systems of communication between Trusts and the IPT system I remain concerned about: i. the lack of progress made in reviewing/renegotiating the SLA bearing in mind the difficulties in this case were drawn to the attention of the Trusts in September 2021. ii. an ongoing firewall problem between the two Trusts as this places a current reliance on email rather than automatic electronic systems especially given the failure of emails in this case to secure a much-needed appointment. ”

    Source location

    Stephen WELLS · Prevention of Future Deaths report
    Page 3 · 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

    Complete review and renegotiation of the inter-Trust SLA, incorporating learning from the inquest, and obtain final organisational sign-off.

    Verbatim wording from the response

    “Both Trusts recognise that greater progress should have been made in reviewing and renegotiating the SLA prior to the Inquest, particularly given that the Trusts were aware of the difficulties in this case in September 2021. We would like to thank you for bringing these issues to our attention both before and during the inquest. Since the inquest the Trusts have been working to ensure that the SLA has been reviewed and renegotiated and that the learning from”

    Source location

    Response from Royal Surrey Foundation Trust NHS
    Page 2 · response
    Published 4 October 2022

    Open published response

  3. Cornwall and Isles of Scilly

    AI-generated summary

    PAUL MATTHEW GILLAM · 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

    Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.

    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 develop and implement the delivery plan in relation to the existing CMHT-Addaction service level agreement

    Wider context from the report

    “(2) The development and implementation of the delivery plan in relation to the existing service level agreement between CMHT and Addaction. ”

    Source location

    PAUL MATTHEW GILLAM · Prevention of Future Deaths report
    Page 3 · 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

    Develop and implement a robust multi-agency implementation plan for the dual diagnosis strategy.

    Verbatim wording from the response

    “A multi-agency steering group has been set up to review the strategy and develop an implementation plan. The steering group consists of key organisations (including CFT and Addaction) and is being supported by the commissioning organisations. The steering group will report progress into the Mental Health Crisis Care Concordat who will report to Safer Cornwall. The Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis and sets out how organisations will work together. These arrangements will ensure the review of the strategy and its implementation, as well as appropriate oversight of progress and effectiveness.”

    Source location

    2019-0045-Response-by-Kernow-CCG
    Page 2 · response
    Published 24 May 2019

    Open published response

  4. Manchester West

    AI-generated summary

    Harry Pryal · 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

    Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

    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 nominated officers to review the operation and performance of Service Agreements

    Wider context from the report

    “ii. The Service Agreement entered into between 5BP and WWL for the period from the 1st April 2014 to the 31st March 2015 was the subject of different interpretations by each Trust. There was confusion in relation to the prioritisation of imaging and there was a fundamental conflict in relation to the interpretation of clause 2.1. The Agreement provided for meetings between nominated officers from each trust at intervals not exceeding every 3 months from the effective date of the Agreement to consider any issues arising from the operation and performance of the Agreement, as provided in paragraph 14.1 on page 10 of the Agreement. The evidence of the Inquest confirmed that no meetings had taken place during the concurrence of the Agreement and there was no proactive involvement of the nominated officers to identify any issues arising from the operation and performance of the Agreement. Furthermore evidence was given that there were similar Service Agreements for the period from 1st April 2013 to the 31st March 2014 and from the 1st April 2015 to the 31st March 2016 with similar provisions for meetings during the concurrence of the Agreements but no meetings between nominated officers had ever taken place. The evidence identified a lack of liaison and understanding between 5BP and WWL in relation to the Agreement and their relationship, even in circumstances where both trusts are operating on the same site at Leigh Infirmary, Leigh. During the Inquest WWL confirmed that they had similar Service Agreements in relation to the provision of services to health professionals in other areas of treatment and the provisions of all Agreements were similar and the provisions in all Agreements may not be performed in accordance with the requirements of each Agreement. ”

    Source location

    Harry Pryal · Prevention of Future Deaths report
    Page 4 · 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

    Review and clarify cross-trust service-level agreements, including specifications, performance information, leads and routine review arrangements.

    Verbatim wording from the response

    “A joint review of all SLAs held between Wrightington, Wigan and Leigh NHS Foundation Trust and 5 Boroughs Partnership NHS Foundation Trust is underway. This includes, and has started with the service level agreement for the provision of radiology services. The review process will incorporate the following steps:”

    Source location

    2015-0391-Response-by-5-Borough-Partnership-NHS-Trust
    Page 2 · response
    Published 28 September 2015

    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

    Complete a joint review of the Radiology Service Agreement to place patient safety at the centre of its specification.

    Verbatim wording from the response

    “Shortly following the conclusion of Mr Pryal’s inquest, discussions were held regarding the interpretation of the Service Agreement for Radiology between the two organisations. Leading on these discussions for the Trust has been ████████ (Associate Director of Finance) and Andrew Beatty (Radiology Directorate Manager), with ████████ (Contract Manager for 5BP).”

    Source location

    2015-0391-Response-by-Wrightington-Wigan-and-Leigh-NHS-Trust
    Page 3 · response
    Published 28 September 2015

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Jayne Jowett · 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

    Jayne Jowett, who was resident in a low secure and locked rehabilitation mental health facility, became unwell with intermittent respiratory difficulties, low oxygen saturations, dizziness, breathlessness and episodes of collapse before she died of a pulmonary embolus on 23 September 2014. The report identified concerns about staff training and response to National Early Warning Scores, understanding of significant clinical signs, and the lack of clear arrangements for sharing physical-health information between the facility and the GP surgery.

    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 a clear service level agreement for PIC and GP joint care

    Wider context from the report

    “3. There remains no clear current service level agreement regarding how best for PIC to work with the local GP surgery to provide high quality joint care. There is no clear guidance that ensures all information regarding a patient’s physical condition is communicated to a GP when seeing a patient. ”

    Source location

    Jayne Jowett · 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

    Maintain a Service Level Agreement with the local GP practice for joint care.

    Verbatim wording from the response

    “Annesley House works closely with the local GP practice at Ashfield House Surgery. I am pleased to say that we have a Service Level Agreement in place and a copy of this is attached.”

    Source location

    2015-0175-Response-by-Partnership-in-Care
    Page 2 · response
    Published 1 May 2015

    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