Recurring concern

Unreliable coordination of referrals between healthcare teams

First to latest report 21 Nov 2013 — 17 Dec 2025

Reports that mention this concern
19
Times this concern has been raised
23
Stated actions linked to this concern
41

What this concern includes

Includes failures in the dedicated coordination of referrals between healthcare teams or organisations, including unclear or unshared referral criteria, missing responsibility and communication arrangements, restricted or inappropriate referral routes, and failures to accept, transfer or coordinate referrals.

What is not included
  • Excludes generic inter-team communication or coordination failures where no referral process is involved.
  • Excludes failures in assessment, treatment or follow-up after a referral has been reliably accepted and coordinated.
  • Excludes service-capacity or waiting-time deficiencies where referral coordination itself is not the unsafe condition.
  • Excludes condition-specific referral pathways, including the existing mental-health referral-pathway concern, when that named pathway provides the more specific supported boundary.

Reports and published responses 19 reports

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

  1. Liverpool and the Wirral

    AI-generated summary

    Dorothy Ann MACDONALD · 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

    Dorothy Ann MACDONALD sustained a fractured neck of femur in an unwitnessed fall at her nursing home on 11 August 2025 and died in hospital on 22 August 2025 after being placed on palliative end-of-life care. The report raised concerns that her falls risk and the potential impact of a fall were repeatedly underestimated, and that staff training and referrals to the falls team were not consistently effective or used.

    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 consistently identify and make appropriate referrals to the falls team

    Wider context from the report

    “In addition, the court was shown that the nursing home’s fall policy indicated that it is good practice to refer cases of falls to the ‘falls team’, but that in practice this was done rarely, partly because the Home Manager lacked confidence in the responsiveness or value of the service. She said that the policy did not specify how many falls should take place prior to a referral. The court would like to know how the nursing home will satisfy itself: (a) that all relevant staff have received, understood and consistently act upon suitable and sufficient education about the circumstances in which, and how, a referral to the falls team should be made; (b) that the service is sufficiently responsive and effective in responding to requests for its specialist input. ”

    Source location

    Dorothy Ann MACDONALD · 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

    Review the Falls Policy to determine whether more specific referral guidance should be included.

    Verbatim wording from the response

    “Springcare are currently reviewing their Falls Policy to determine whether further, more specific guidance can be included regarding when and in what circumstances a referral to the Falls Team should be made.”

    Source location

    Response from Springcare West Wood Hall
    Page 3 · response
    Published 19 December 2025

    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

    Refer every resident who falls to the Falls Team and inform staff of this approach.

    Verbatim wording from the response

    “In the interim and in response to the concerns raised, Westwood Hall has adopted the approach of referring any resident who has fallen, regardless of the circumstances, to the Falls Team. Staff have been made aware of this new approach.”

    Source location

    Response from Springcare West Wood Hall
    Page 4 · response
    Published 19 December 2025

    Open published response

  2. Inner North London

    AI-generated summary

    Costas CHRYSOSTOMOU · 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

    Costas Chrysostomou died in hospital on 14 December 2024 after developing cardiac failure and acute renal failure linked to pacemaker-mediated cardiomyopathy, described as a rare but known complication. The report raised concerns about ambiguity in the use of “urgent” referrals, differing understandings of cardiology pathways between GPs and hospital consultants, and the need for clearer guidance for complex cases.

    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

    Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways

    Wider context from the report

    “1) Use of the term ‘urgent’ and understanding by third-party providers of the specific Pathways available Following implantation of the pacemaker, Mr Chrysostomou’s GP was charged with arranging a follow-up outpatient cardiology appointment and arranging for an echocardiogram (Echo). Both actions were undertaken by the GP. A referral to the cardiology team at the Royal Free Hospital was made under what I was told was a ‘generic’ cardiology pathway as there was no expectation, at that time, for a more specific pathway to be used. The Echo was undertaken by a third-party (private) provider, contracted to provide services to the NHS. The Echo report was headed in large bold writing: ‘Suggest Urgent Cardiac Referral’. The bottom of the Echo report repeats that recommendation next to the heading ‘Onward Recommendations’. The evidence I heard indicated that there are numerous potential cardiac/cardiology pathways available. The concern regarding the use of the term ‘urgent’ is that I heard evidence that this is open to interpretation; for example, there is in some Pathways an ‘Urgent 6 weeks’ type of referral and also an ‘Urgent (<2 weeks)’ type of referral. It is possible that the third-party provider(s) may not be aware of the differences and/or not sufficiently aware of the NHS ICB Pathways available, which is leading to confusion. ”

    Source location

    Costas CHRYSOSTOMOU · 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

    Update the suspected heart failure pathway to clarify urgent referral routes and align them with two-week and two-to-six-week clinic provision.

    Verbatim wording from the response

    “An NCL pathway already exists for Suspected Heart Failure assessment and diagnosis on the NCL GP professional website. However, we recognise that there was a lack of clarity in referral pathways for urgent assessment in a patient with heart failure at the Royal Free whereby the GP referral was being sent in through the (Clinical Assessment service) CAS triage system- however the service was unable to guarantee that the urgent echo investigation would be reviewed within 2-6 weeks. We have since contacted the Royal Free Heart Failure Lead and in line with the service provision for urgent 2 week and 2-6 weeks clinic provision, changes have now been updated on the NCL Pathway for Suspected Heart Failure Download: Heart Failure Diagnosis and Assessment in Adults - NCL ICB General Practice Website.”

    Source location

    Response from North Central London Integrated Care Board
    Page 2 · response
    Published 7 April 2026

    Open published response

  3. Cumbria

    AI-generated summary

    Janet Scott · 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

    Janet Scott, who had schizophrenia and diabetes and was at serious risk of self-neglect, was found unresponsive at home on 28 March 2023 after concerns about her living conditions and welfare had been raised. She died in hospital on 30 March 2023 after developing sepsis. The report identified missed opportunities to provide assistance and a failure to activate multi-agency safeguarding procedures, raising concern that safeguarding referrals may not be made when agencies assume others are already aware.

    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 make safeguarding referrals when other agencies are thought to be aware

    Wider context from the report

    “(1) Although individual agencies referred me to training they had provided to staff since Ms Scott's death, I also received evidence that, for instance, the GP surgery might not raise a safeguarding referral if the same circumstances were repeated because social services had already been informed. This leads me to be concerned that the message that 'safeguarding is everyone's responsibility' has not been taken on board. I am concerned that future cases will occur in which a multiagency approach is not adopted or that individuals will not make safeguarding referrals because they assume that other agencies are already aware of the issue. ”

    Source location

    Janet Scott · 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

    Audit cases involving self-neglect risk, assess referral, escalation and management oversight, and share findings with partners for practice review.

    Verbatim wording from the response

    “Audits of clients at risk of self-neglect have evidenced a range of referral sources including (but not limited to) family, friends and neighbours; community health staff; probation workers; fire service personnel and GPs. Close examination of records includes historic cases as well as recent referrals and consideration of whether appropriate and timely action was taken (including escalation to safeguarding procedures) and if there has been sufficient management oversight. Findings from these audits will be shared with partners across NCASP via the task and finish group once completed and implications for practice considered and kept under review.”

    Source location

    Response from Northumberland Children's and Adults Safeguarding Partnership
    Page 2 · response
    Published 27 February 2025

    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

    Introduce a multi-agency risk management framework within six months for earlier intervention and referrals involving adults with complex needs and serious-risk concerns.

    Verbatim wording from the response

    “Multi-agency Risk Management (MARM) Framework NCASP will introduce a multi-agency risk management framework within 6 months, which will set out a shared commitment across agencies who work with risk in Northumberland and will provide practice guidance to practitioners who are working with adults who have multiple and complex needs and are at risk of serious harm or abuse. This framework will support professionals to provide earlier multi-agency intervention than traditional safeguarding procedures and encourage referrals for low level concerns before they become significant and critical.”

    Source location

    Response from Northumberland Children's and Adults Safeguarding Partnership
    Page 3 · response
    Published 27 February 2025

    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

    The Integrated Care Board is leading work to ensure escalation processes and safeguarding responsibilities are understood across primary care services.

    Verbatim wording from the response

    “In addition, as a Statutory Partner, the Integrated Care Board are taking the lead in relation to ensuring escalation processes and safeguarding responsibilities are widely known and understood across Primary Care services and will ensure evidence of this is shared with NCASP.”

    Source location

    Response from Northumberland Children's and Adults Safeguarding Partnership
    Page 3 · response
    Published 27 February 2025

    Open published response

  4. Inner West London

    AI-generated summary

    Judith Maike OBHOLZER · 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

    Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.

    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 clarity in referral and crisis-support processes for patients receiving private and NHS treatment

    Wider context from the report

    “1. In the course of the evidence it was confirmed that there is a significant pressure on NHS mental health services. It seems likely that there will be an increase in patients obtaining private support while waiting for NHS support (and often only being able to afford such support for a limited time and to a limited extent and doing so only while waiting for NHS support), as happened in this case. Consideration should be given to ensuring that there is sufficient clarity in processes such as referrals and crisis support where private practitioners are providing treatment as well as the NHS, ensuring sharing of information and notes where relevant and necessary and ensuring that the NHS provision is not assessed as unnecessary simply because someone has obtained private support as an interim measure. ”

    Source location

    Judith Maike OBHOLZER · 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

    Maintain a ratified Private Providers Shared Care Policy defining Trust and private-provider roles and responsibilities.

    Verbatim wording from the response

    “However, in addition to the DH guidance, the Trust has a ‘Private Providers Shared Care Policy’ (Appendix 1) which was ratified in January 2024. This clearly sets out the respective roles and responsibilities of the Trust and private providers. This policy was drafted with input from Consultant Psychiatrists from a private provider and supplements the DH guidance to add specific clarity for the Trust.”

    Source location

    Response from SW London Mental Health Trust
    Page 2 · response
    Published 31 July 2024

    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

    Make the Private Providers Shared Care Policy accessible on the Trust website and communicate its existence internally and through local GP networks.

    Verbatim wording from the response

    “The Trust accepts that this policy was not referenced and it appears there was a lack of appreciation that the policy existed during the Inquest. In response to the concern raised in the PFDR, the Trust will ensure this policy is made accessible on the Trust's website (in the GPs/Professionals section of our website) and its existence will be further communicated internally and also through our local GP networks.”

    Source location

    Response from SW London Mental Health Trust
    Page 2 · response
    Published 31 July 2024

    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

    Improve and publish prominent website information directing healthcare professionals to urgent mental-health crisis referrals, including the 24/7 crisis line.

    Verbatim wording from the response

    “In response to the PFDR, the Trust has reviewed and further improved the information available for all healthcare professionals on the Trust website to ensure it is more easily accessible. The link (button) on the front page of the website is now red to make it even more prominent and marked ‘Urgent Help’ (Home - Website (swlstg.nhs.uk)).”

    Source location

    Response from SW London Mental Health Trust
    Page 3 · response
    Published 31 July 2024

    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

    Share crisis-referral information externally through social media, website news articles, and campaign materials.

    Verbatim wording from the response

    “Additionally, we have again shared our crisis information externally, which we do at regular intervals. This includes on social media and in extra places on our website including news articles and in information about our campaigns.”

    Source location

    Response from SW London Mental Health Trust
    Page 5 · response
    Published 31 July 2024

    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

    Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.

    Verbatim wording from the response

    “The Trust will remind all staff of the ‘Urgent Care Pathway’ in a Monthly Learning Bulletin article (to be published by October 2024). Staff will also be reminded to regularly check if service users are receiving private treatment and discuss consent to share information. Staff will also be signposted to the Trust’s ‘Private Providers Shared Care Policy’, so they are aware of the process if they are contacted by a private provider regarding a patient in crisis. This policy will also be shared through our local GP networks.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 2024

    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

    Review the interface between NHS and non-NHS-funded independent health providers.

    Verbatim wording from the response

    “Work is also in progress to review the interface between the NHS and non-NHS funded independent health providers. This work is in its infancy, but NHS England can provide an update to the Coroner in due course if this would assist. We understand that the Care Quality Commission (CQC) are also undertaking work regarding standards for online care and are exploring opportunities for better sharing of information both into private sector providers and receiving information back to the patient’s registered GP practice from private providers.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 31 July 2024

    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

    No national or local system provides contact details for every private provider, so referral information cannot feasibly reach all providers.

    Verbatim wording from the response

    “Unfortunately, there is currently no national or local system which enables the Trust to have the contact details of every private provider operating in its catchment area and, therefore, it is not feasible to provide information about the referral process to all these providers and those we are not aware exists. Furthermore, in Mrs Obholzer’s case, the private provider that gave evidence at the Inquest and who assessed Mrs Obholzer shortly before her death, was not based in the catchment for our Trust.”

    Source location

    Response from SW London Mental Health Trust
    Page 2 · response
    Published 31 July 2024

    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

    Private providers can refer patients directly to crisis services through the Mental Health Crisis Line, 111, 999 or A&E.

    Verbatim wording from the response

    “However, the Trust would like to assure the Coroner that private providers can refer their patients to the Trust’s crisis services when required. Private providers can telephone or make a referral about someone they are concerned for to our crisis services via the Trust’s Mental Health Crisis Line in the same way as a GP or other non-Trust health professional. If a private provider contacts the Mental Health Crisis Line, advice will be provided, and their patient will be directed into the correct care pathway dependent upon the patient’s presentation and risk factors. In an emergency scenario, private providers can also call 999 or 111 and patients are able to attend A&E to access the pathway for crisis services.”

    Source location

    Response from SW London Mental Health Trust
    Page 3 · response
    Published 31 July 2024

    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

    The relevant NHS mental health trust is responsible for providing further information about its emergency referral signposting for private providers.

    Verbatim wording from the response

    “NHS England has also engaged with South West London and St George’s Mental Health NHS Trust. They have advised us that at the time Judith required NHS crisis support, their website provided clear signposting for private providers needing to make an emergency mental health referral. Since receiving your Report, we also note that they have made this more visually prominent on the website. I will refer you to the Trust for further information, who I understand are issuing their own response to you.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 31 July 2024

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Emily Corfield · 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

    Emily Corfield, aged 41, was found deceased at home on 19 September 2021 after a history of alcohol misuse and two hospital admissions for coffee ground vomiting and alcohol withdrawal. The principal concern was the lack of evidence that the alcohol liaison team provided inpatient or outpatient support or that referrals to external organisations were made.

    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 systems and processes to ensure completion of alcohol liaison team referrals

    Wider context from the report

    “Emily had two inpatient admissions in the year of her death. Whilst the clinician had noted that she was for referral to the alcohol liaison team there was no evidence that Emily had in fact received any input from them either as an inpatient or as an outpatient nor any referrals to external organisations. It is concerning that there appears to have been no evidence that Emily was receiving support from the Alcohol Liaison Team whilst an inpatient on either occasion despite her long history of alcohol misuse and need for support. In the event that clinicians advise referral to alcohol liaison team, either as an inpatient or as an outpatient there ought to be systems and processes to ensure that this occurs. ”

    Source location

    Emily Corfield · 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

    Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.

    Verbatim wording from the response

    “In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

    Source location

    Response from Adferiad
    Page 3 · response
    Published 21 July 2023

    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

    Implement and roll out the updated service specification to all staff by the end of September 2023.

    Verbatim wording from the response

    “In addition, concerning the monitoring of support, the new system, amongst other things, allows a “red flag” to be displayed for those patients who are considered to be a risk to themselves or others, has the option to add viewable risk management plans, records signposting that has taken place and has an internal referral system to refer patients directly to another service. Further, if a patient leaves the service, staff need to input the exit date, reason and other relevant information. Adferiad is updating its service specification to incorporate these requirements. The updated service specification will be implemented and rolled out to all staff by the end of September 2023.”

    Source location

    Response from Adferiad
    Page 3 · response
    Published 21 July 2023

    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

    Issue communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.

    Verbatim wording from the response

    “During consideration of your concerns, it was identified that the liaison service did not receive a referral from the treating team located in our Integrated Health Community (East). In response to this, a communication has been produced that outlines the referral process to liaison services that will be shared with clinical teams across the Health Board to ensure there is clarity and consistency across all areas. This communication has now been issued.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 21 July 2023

    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

    Review the liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.

    Verbatim wording from the response

    “Although in date and operational, the MHLD Liaison Psychiatry Services in Acute Hospitals Delivery Framework will be reviewed by a working group of stakeholders, to include liaison team managers and key clinicians, led by a senior manager to ensure the referral process is clear and unambiguous.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 21 July 2023

    Open published response

  6. Nottinghamshire

    AI-generated summary

    Gordon Harry Renfrew · 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

    Gordon Harry Renfrew died at Queens Medical Centre on 14 June 2022 after a severe and extensive stroke caused by a large cerebral infarction. The report identified concerns about limited communication and working relationships between the stroke and neurosurgical teams, limited understanding of NICE guidance on decompression craniectomy, and insufficient opportunities for joint case discussion and learning. It stated that the NICE guidance was not followed and that discussions with the family about the timing of decompression craniectomy should have occurred earlier.

    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 finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria

    Wider context from the report

    “• There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised. ”

    Source location

    Gordon Harry Renfrew · 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

    Finalise and circulate a cross-department SOP incorporating NICE guidance, monitoring requirements and referral criteria for decompressive hemicraniectomy.

    Verbatim wording from the response

    “There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure which may set out this clarity is not yet finalised.”

    Source location

    Response from Nottingham University Hospital
    Page 3 · response
    Published 7 July 2023

    Open published response

  7. Birmingham and Solihull

    AI-generated summary

    Spencer George BARR · 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

    Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.

    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 organisations to accept direct referrals from other agencies

    Wider context from the report

    “5. Furthermore, I heard evidence that certain organisations do not accept direct referrals or share information between agencies. For instance, I heard that CGL solely depend on referrals from GP practices and do not allow referrals direct from other agencies. Consideration therefore should be given as to whether there a better system of interagency referral is possible ”

    Source location

    Spencer George BARR · 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

    Continue working with partner agencies to refine and improve inter-agency referral processes through commissioning review.

    Verbatim wording from the response

    “Response – insofar as this relates to Probation, the commissioning of rehabilitative services and the making of referrals is subject to regular review as part of the commissioning processes and Probation is committed to continuous improvement and will continue to work with partner agencies to refine and improve referral processes.”

    Source location

    Response from Probation Service
    Page 2 · response
    Published 17 May 2022

    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

    Develop a fast-track trusted-assessment pathway to expedite mental-health referrals from CGL.

    Verbatim wording from the response

    “CGL have direct access to referring into FTB and can directly refer young people where there are mental health concerns and substance misuse concerns this has been strengthened further with the agreement of the development of a fast-track pathway and expediting referrals for mental health assessment from CGL via a trusted assessment model. We believe this will support patients at the earliest opportunity addressing risk. The oversight of the task group and progress will be monitored through the Birmingham Joint Strategic Operational forum where all system partners are represented.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 3 · response
    Published 17 May 2022

    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

    CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.

    Verbatim wording from the response

    “We would like to reassure you that CGL have an established central point of contact and have accepted referrals from any individual and agency since March 2015 when the service was commissioned in Birmingham. Referrals can be made via the telephone or the CGL website at the following link https://www.changegrowlive.org/drug-alcohol-service-birmingham/referrals.”

    Source location

    Response from Birmingham Women's and Children's NHS Foundation Trust
    Page 4 · response
    Published 17 May 2022

    Open published response

  8. Manchester South

    AI-generated summary

    Mark Jones · 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

    Mark Deardon Jones died at home on 13 November 2020 after a catastrophic haemorrhage at the site of surgery for squamous cell carcinoma of the tongue. Concerns included delays in standard referral pathways and the absence of a national protocol for routinely providing photographs and consistent information to support triage of dental referrals.

    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 standard protocol for routine provision of referral photographs to assist triage

    Wider context from the report

    “1. During the inquest the Court was told that there is a backlog in standard referrals such as Mr Jones being seen. This means that a referral which pre Covid meant a waiting time of approximately 2.5 months for an outpatient appointment now involves a waiting time of approximately 8 months. 2. Mr Jones’ referral was sent in by his dentist to secondary care on the standard referral pathway. On receipt by the secondary care triage team the referral was assessed and based on the information provided remained on the standard referral pathway. The evidence was that a more detailed and better quality referral that included a photograph of the lesion would have probably resulted in his case being moved off the standard pathway. The inquest was told that there is no national standard or protocol in place between dentists and secondary care to provide for the routine provision of photographs to assist in triage. Such a protocol to ensure the provision of photographs by referring dentists in conjunction with more consistent provision of information would, the inquest was told, be helpful in improving the quality of triage and reduce the risk of patients needing urgent care being missed. ”

    Source location

    Mark Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Norfolk

    AI-generated summary

    Peter Frosdick · 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

    Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

    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 teams to understand each other's referral criteria

    Wider context from the report

    “(3) The various teams within the Trust seem to be unaware of each other's referral criteria and displayed little or no professional curiosity and appeared to dismiss his GP's opinion which gave a clear description of his worsening presentation and the fact that he had been abstinent from alcohol. ”

    Source location

    Peter Frosdick · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester West

    AI-generated summary

    Angela Mary Jackson · 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

    Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.

    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 approved documented pathways for referral and treatment of aortic aneurysms

    Wider context from the report

    “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons. The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital. ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital. iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence. iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams. v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment. ”

    Source location

    Angela Mary Jackson · 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

    Publish and distribute the Liverpool Acute Network for Thoracic Aortic Services pathway across the region and on the Trust website.

    Verbatim wording from the response

    “A pathway was agreed between LiVES and LHCH and published known as Liverpool Acute Network for Thoracic Aortic Services (LANTAS), (Appendix 1). This was distributed around the region and placed on the LHCH Website.”

    Source location

    Angela-Jackson-Response-1
    Page 2 · response
    Published 26 September 2018

    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

    Produce three regional referral pathways covering Cheshire and Merseyside, Wythenshawe and MRI, and Lancashire including Blackpool.

    Verbatim wording from the response

    “Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.”

    Source location

    Angela-Jackson-Response-1
    Page 3 · response
    Published 26 September 2018

    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

    Publish the Manchester and Lancashire referral pathway documents and distribute the pathways to emergency departments.

    Verbatim wording from the response

    “Three referral pathways have been produced between Cheshire and Merseyside Health and Care Partnership (LHCH) (Appendix 1), Wythenshawe Hospital and MRI (Appendix 3) and Lancashire including Blackpool (Appendix 4). Liverpool Heart and Chest have published their pathway on the Trusts website and Manchester and Lancashire will publish their documents in due course. The pathways will also be distributed to A&E departments and Liverpool will put this proposal forward to the CCG at their next meeting in December. This essentially provides sign posting for referring hospitals describing how to navigate the pathways and ensure the patient ends up expediously at the correct destination. Key Quality Markers are published in terms of time to make the diagnosis, early medical management and referral and transfer arrangements.”

    Source location

    Angela-Jackson-Response-1
    Page 3 · response
    Published 26 September 2018

    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

    Finalise and obtain approval for the Lancashire and South Cumbria pathway for managing aortic aneurysms.

    Verbatim wording from the response

    “Prior to the inquest of Mrs Jackson, work had already begun within our organisation on producing a pathway for the Lancashire and South Cumbria Vascular Network. It is clear that this work needed to be extended to include the whole of the North West region incorporating all the specialist cardiothoracic centres and referring hospitals.”

    Source location

    Angela-Jackson-Response-1
    Page 3 · response
    Published 26 September 2018

    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

    Share the Lancashire and South Cumbria pathway and clinical algorithm with Medical Directors and Emergency Departments across the vascular network.

    Verbatim wording from the response

    “• Sharing both the pathway and clinical algorithm with all Medical Directors and Emergency Departments across the Lancashire and South Cumbria Vascular Network.”

    Source location

    Angela-Jackson-Response-1
    Page 4 · response
    Published 26 September 2018

    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

    Implement formally agreed written guidance for Greater Manchester acute aortic syndrome referrals and distribute it to covered hospitals and healthcare professionals.

    Verbatim wording from the response

    “The concerns are acknowledged in their entirety by Manchester University NHS Foundation Trust. Steps have been taken in order to create and work towards implementing formalised written guidance on the referral system to the Trust for treatment of patients with aortic aneurysms and other conditions. The pathway has now been formally agreed at the Trust”

    Source location

    Angela-Jackson-Response-1
    Page 4 · response
    Published 26 September 2018

    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

    Continue consulting with Liverpool Heart and Chest Hospital and modifying Manchester’s referral guidance in line with wider cardiothoracic strategy and service specifications.

    Verbatim wording from the response

    “Mr Bilal has consulted directly with colleagues at LHCH in respect of this written guidance; Mr Manoj Kuduvalli, Consultant Surgeon and Associate Medical Director for Surgery and Mr Mark Field, Aortic Lead, specifically considering alignment with the pathway provided by Mr Field on behalf of LHCH. Our Trust's guidance is agreed in principle by LHCH and is subject to ongoing consultation, discussions and modifications in line with wider cardiothoracic strategy and service specifications.”

    Source location

    Angela-Jackson-Response-1
    Page 6 · response
    Published 26 September 2018

    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

    Publish vascular surgery service specifications requiring networked arrangements and agreed pathways with non-arterial services.

    Verbatim wording from the response

    “Service specifications have been published for vascular surgery¹ that make clear the need for networked arrangements and agreed pathways for specialised vascular services with non-arterial services, though they do not address the cross over with cardiac surgery.”

    Source location

    Angela-Jackson-Response2
    Page 1 · response
    Published 26 September 2018

    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

    Develop a service specification for aortic aneurysm management, identifying specialist hospitals, team responsibilities, referral communication and clear pathways.

    Verbatim wording from the response

    “You will be interested to know that work has been commissioned for the national cardiac and vascular clinical reference groups to address the surgical management of aortic aneurysms (including descending thoracic aneurysms) and produce a service”

    Source location

    Angela-Jackson-Response2
    Page 1 · response
    Published 26 September 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

    Formal organisation of thoracoabdominal aortic services and pathways will be addressed by NHS England’s national service specification.

    Verbatim wording from the response

    “National Aortic Service Specification will eventually provide statutory requirements to organise service within the North West of England.”

    Source location

    Angela-Jackson-Response-1
    Page 2 · response
    Published 26 September 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

    NHS England and national cardiac and vascular clinical reference groups are responsible for developing the service specification and addressing aortic aneurysm pathways.

    Verbatim wording from the response

    “Your report raises concerns about the absence of documented pathways for the treatment of aortic aneurysms nationally. My officials have made enquiries with NHS England, as commissioner of specialised services, and I am able to offer the following information.”

    Source location

    Angela-Jackson-Response2
    Page 1 · response
    Published 26 September 2018

    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