Recurring concern

Unreliable vascular surgery referral pathways

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First reported 27 Oct 2023•Latest report 13 Mar 2024

Definition

What this concern includes

Includes failures in vascular surgery referral arrangements, including regional pathway design, referral criteria, routing, cross-provider responsibilities, recognition of when urgent referral is required and use of efficient referral routes.

Not included

  • Excludes vascular surgery staffing, specialist-service capacity and treatment delays where the referral pathway itself is not deficient.
  • Excludes generic referral or communication failures without a material vascular surgery referral context.
  • Excludes failures occurring after a vascular referral has been reliably completed and accepted, including specialist assessment and surgery.
  • Excludes unrelated vascular surgery clinical guidance or treatment decisions where no referral-pathway deficiency is identified.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2023–2024

First to latest report issue date

Stated actions
5

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.

NHS Greater Manchester Integrated Care Board1
Oxford University Hospitals NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Alan William Rowland 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

    Alan William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.

    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 understanding of the need for prompt referral to vascular services

    Wider context from the report

    “1. The inquest heard evidence that a prompt referral to vascular services was important in cases such as these, where GPs would have limited expertise in managing the risks and offering effective treatments. The need for early referral was not, the inquest was told, widely understood. ”

    Source location

    Alan William Rowland Smith · 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

    Deliver a Masterclass on timely vascular and District Nursing referrals, including required referral information and examples of good referrals.

    Verbatim wording from the response

    “In light of the findings in this case, a Masterclass learning event will be delivered in September 2024 to include advice and guidance in relation to the circumstances in which to refer and the information required within a referral to ensure timely triage and progression to care under the vascular surgery team as appropriate.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 1 · response
    Published 19 March 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 GP practice considers that Mr Smith’s leg-swelling management, compression hosiery and District Nursing referral were clinically appropriate.

    Verbatim wording from the response

    “Following the inquest and the issuing of the Regulation 28 in this case, the GP partners have undertaken a full review of Mr Smith’s journey of care, focusing on the timing of referrals into specialist services including referrals to the vascular surgery team. The practice maintain that the management of Mr Smith’s leg swelling was appropriate.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 1 · response
    Published 19 March 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

    GPs can refer uncertain leg-swelling cases to vascular services for specialist triage and advice.

    Verbatim wording from the response

    “In circumstances where a GP has a query in relation to a leg swelling and whether to refer into vascular surgery, the process is for a referral to be completed so that the vascular team can then triage and determine if the patient is appropriate for them and / or to advise on the way forward.”

    Source location

    Response from Greater Manchester Integrated Care
    Page 1 · response
    Published 19 March 2024

    Open published response

  2. Berkshire

    AI-generated summary

    Francis Osborne Barnes · 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

    Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.

    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

    Unclear vascular surgery referral pathways

    Wider context from the report

    “The focus of my concerns relates to the approach of your Trust to learning from deaths. Although Mr Barnes was not treated at the John Radcliffe Hospital, I concluded that he should have been transferred there, and that the delay in carrying out vascular surgery there contributed to his death. The Oxford Trust has been involved in this investigation almost from the start, and other Interested Persons involved in the investigation have attempted to work with your Trust to investigate the circumstances of Mr Barnes’ death. I have been assisted by investigation reports and statements from the Spire Dunedin Hospital, and Royal Berkshire Hospital. This, I am afraid, sits in stark contrast to the response and approach by the Oxford Trust. The Oxford Trust has carried out no investigation. They did not co-operate with the offer to conduct a joint investigation with Royal Berkshire Hospital. There is no recorded morbidity and mortality meeting minute, although we were told at inquest that the case was discussed. There is no recorded MDT meeting minute, although we were told at inquest that the case was discussed. There is no evidence of proposed changes beyond evidence in court during the inquest that “we are looking into this”. Whilst I accept entirely that a knee-jerk response, even following a tragic death, is not appropriate, it is now some 18 months since Mr Barnes’ death. Evidence from RBH and Spire Dunedin was consistent, namely that attempts to liaise with your trust and learn from this event jointly have been universally ignored. It was also difficult for my office to obtain evidence for the inquest. We were provided with a joint statement, from three consultant vascular surgeons (only two of whom were clinically involved). It transpired that this statement was written by a clinical governance manager, and each of the witnesses who gave evidence was careful to tell the court that they did not agree with the wording of that statement. We subsequently received a statement from the consultant vascular surgeon in this case on the 29th of September, and from the clinical lead of vascular surgery some 5 days before the inquest started. We were also informed 11 days before the inquest started that the key vascular surgery witness would be on holiday abroad. This witness was summoned in May 2023. He ultimately gave evidence by video link, but this was difficult technically, and arrangements would have been made for him to attend in person, had we been made aware of this holiday arrangement, even aside from the fact that he had been formally summoned. Multiple attempts have been made by the other Interested Persons in this case (notably Royal Berkshire Hospital and Spire Dunedin Hospital) to discuss the issues arising, but each of these offers has been ignored. The key clinical issues in this respect have been clarification of vascular surgery pathways, and use of an OARS system (or similar). No records were made by the vascular surgery consultant involved, despite being consulted several times about the same patient in a short space of time, and the fact that there was a clinical difference of opinion about where the patient should best be managed. We heard no evidence of a reason for the failure to engage with processes specifically aimed at learning from deaths – whether resourcing or any other reason. The matters of concern can be summarised as follows: 1. Clarification of vascular surgery pathways - i.e. working with others in the Thames Valley network to consider how patients should be efficiently referred to the vascular team, wherever that patient is physically based (including in the private sector). 2. Consideration of an electronic referral system (such as OARS). I note that OARS was set up by the Oxford Trust itself, and is already in operation in a neurosurgery context, and indeed even for some vascular surgery patients. 3. Consideration of how the Oxford Trust responds to and learns from deaths. ”

    Source location

    Francis Osborne Barnes · 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 approve a concise TVVN vascular emergency referral procedure.

    Verbatim wording from the response

    “1. Clarification of vascular surgery hub pathways”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 6 November 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

    Disseminate the approved vascular emergency referral procedure to NHS and private Thames Valley providers.

    Verbatim wording from the response

    “1.1 Following this inquest, a concise procedure for contacting the Vascular Team at OUH has been developed and approved by the TVVN which clearly sets out the referral process for patients who have a vascular emergency within the network. This will be sent to all NHS and private providers in Thames Valley and provides details on how to contact the on-call Vascular SpR and on-call Vascular Consultant.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 6 November 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

    Appraise options for documenting TVVN vascular referrals and consultant advice.

    Verbatim wording from the response

    “2. Consideration of an electronic referral system”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 6 November 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 a Microsoft 365 Form to document emergency vascular referrals from across the TVVN.

    Verbatim wording from the response

    “2.3.1 The use of a Microsoft 365 Form which will enable all referrals to be documented in real time including a record of the patient’s name and NHS number. This does not require the patient to have an existing OUH medical record number (MRN) and so allows documentation of referrals of patients who are not currently under the care of OUH. This Form is currently used by the vascular surgical team to track patients from around the region who are awaiting discussion at the Multidisciplinary Team meetings. The data is stored within the OUH server on Sharepoint.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 3 · response
    Published 6 November 2023

    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

    Telephone referral to the on-call vascular team is considered more timely and effective than any electronic referral system for vascular emergencies.

    Verbatim wording from the response

    “2.2 The TVVN have agreed that all vascular emergencies should continue to be referred by telephone to the on-call vascular surgical team at OUH. No electronic referral system would ensure as timely and effective a response to vascular emergencies.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 2 · response
    Published 6 November 2023

    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 existing clinical audit and research system cannot document referrals across the network because it requires an existing OUH electronic patient record.

    Verbatim wording from the response

    “2.3.2 A clinical audit and research system is currently used to document every inpatient encounter and vascular operation within Vascular Surgery in OUH. It could be used to document referrals to the vascular service; however, it is dependent on the patient having an existing OUH Electronic Patient Record (EPR) and so would not be suitable for documenting referrals from across the TVVN.”

    Source location

    Response from Oxford University Hospitals NHS Foundation Trust
    Page 3 · response
    Published 6 November 2023

    Open published response
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Data last updated 7 September 2026