Recurring concern

Unreliable internal hospital referral processes

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First reported 16 Dec 2013•Latest report 4 Nov 2021

Definition

What this concern includes

Includes failures in internal hospital referral processes that impair timely creation, routing, filing, electronic availability, retrieval or clinician access to referrals and the associated clinical information needed for patient care.

Not included

Excludes general clinical-record delays or scanning problems where no internal hospital referral process is involved.
Excludes external referrals between separate organisations unless the assertion explicitly concerns the same internal hospital referral process.
Excludes failures in the clinical quality of referral decisions or specialist care after the referral has been reliably received and made available.
Excludes generic IT, documentation or communication deficiencies that do not directly impair internal hospital referrals.

Reports: 2
Individual concerns: 3
Date range: 2013–2021
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cwm Taf Morgannwg University Local Health Board1

Surrey and Borders Partnership 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.

4 Nov2021
South Wales Central
Concerns raised2
1. Delays in placing paper referrals in patient notes
2. Reliance on paper referrals for internal hospital referrals
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Plan and develop online presentation, triage and vetting of hospital referrals for Consultant review.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
2. Action
  Continue transitioning patient records to electronic access, reducing reliance on paper records.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
3. Action
  Train staff to access patient information through the electronic record and related online systems.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
Respondent positions 1
1. Position
  The missing referral information probably would not have changed the patient’s outcome.
  Stated by Cwm Taf Morgannwg University Local Health BoardDisputes the concern
AI-generated summary

Robert Wright · 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

Robert Wright, aged 80, died at Prince Charles Hospital on 26 July 2019 after his condition deteriorated; post-mortem examination identified necrotising cholecystitis caused by gallstones. The principal concern was that a hospital referral for consideration of cholecystectomy was not available to the consultant surgeon because paper referrals were routinely added to patient notes only shortly before clinic appointments, creating a risk that clinicians may not have all relevant information.

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
Delays in placing paper referrals in patient notes
Wider context from the report
“(1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper (2) Those paper referrals were routinely not placed on the patient’s notes until 2-3 days prior to the clinic, in this case many weeks after being made. (3) In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient’s referrals and condition (4) A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made. ”
Source location
Robert Wright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on paper referrals for internal hospital referrals
Wider context from the report
“(1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper (2) Those paper referrals were routinely not placed on the patient’s notes until 2-3 days prior to the clinic, in this case many weeks after being made. (3) In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient’s referrals and condition (4) A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made. ”
Source location
Robert Wright · 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
Plan and develop online presentation, triage and vetting of hospital referrals for Consultant review.

Verbatim wording from the response
“With regards to the first matter, referrals from General Practice are available on an IT system, however, these referrals are presented to the Consultant body for review on paper. The paper referrals are then triaged and patients are assigned to the appropriate clinics on an appropriate pathway.”

Source location
2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
Page 2 · response
Published 9 November 2021
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 transitioning patient records to electronic access, reducing reliance on paper records.

Verbatim wording from the response
“The clinic letters, with the triage outcome, are placed in the patient’s notes and are available for the Consultant team prior to the patient’s appointment in clinic. However, if the referral letter were not actually present in the patient’s physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient’s records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required.”

Source location
2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
Page 2 · response
Published 9 November 2021
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
Train staff to access patient information through the electronic record and related online systems.

Verbatim wording from the response
“The clinic letters, with the triage outcome, are placed in the patient’s notes and are available for the Consultant team prior to the patient’s appointment in clinic. However, if the referral letter were not actually present in the patient’s physical notes, the medical team would refer to the Welsh Clinical Portal where the referrals are evident. We wish to note that we have moved towards the electronic patient record and a large number of patient’s records are no longer available in clinics in a paper format as we recognise that relying on paper is a risk. These notes are available to medical staff online and our staff have received training onto how to access information as required.”

Source location
2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
Page 2 · response
Published 9 November 2021
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 missing referral information probably would not have changed the patient’s outcome.

Verbatim wording from the response
“This is true and in this patient’s case, he was already on a waiting list for a cholecystectomy. Had this information been available, this would have probably not changed the outcome.”

Source location
2021-0374-Response-from-Cwm-Taf-University-Health-Board_Published
Page 2 · response
Published 9 November 2021
Open published response
16 Dec2013
Surrey
Concerns raised1
1. Failure to require written and reasoned referral responses and their recording in patient notes
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sarah Anne Shepherd · 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

Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.

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 require written and reasoned referral responses and their recording in patient notes
Wider context from the report
“(1) It was clear from the evidence that the Trust has in place an Operational Policy concerning its Psychiatric Intensive Care Services. The Policy in place in September 2011 did not establish a clear process for the referral of an inpatient from an acute ward (or any other patient) to the Psychiatric Intensive Care Unit and it did not require the PICU to provide a written and reasoned response to the referral and to record the same on the patient’s RIO (or other medical) notes. From the evidence heard, it does not seem that these concerns have yet been addressed or sufficiently addressed by amendment of the Operational Policy and consequential staff training. ”
Source location
Sarah Anne Shepherd · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Delays in placing paper referrals in patient notes

Reliance on paper referrals for internal hospital referrals

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to require written and reasoned referral responses and their recording in patient notes

Actions described in response 3

Respondent positions 1