5 Jun 2026 Keith Richard Gandy · Prevention of Future Deaths report North London
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Concerns raised 1
Delays in referral waiting times for specialist evaluation View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Keith Richard Gandy · 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
Keith Richard Gandy died in hospital on 29 October 2025 after deterioration following a fall and was found to have a rare radiation-induced osteosarcoma of the pelvis. The concerns were that guidance did not clearly identify previous cancer as a red flag requiring specialist referral without waiting for further tests, and that specialist evaluation waiting times could be between six and twelve months.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in referral waiting times for specialist evaluation
Wider context from the report “There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests.
That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months
” Source location Keith Richard Gandy · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Specialist referral waiting times are primarily the responsibility of regional commissioners and local providers, not NHS England centrally.
Verbatim wording from the response “Referral waiting times
This is primarily a matter for the region and the commissioners and providers in the locality. However, we would note that in this instance, the patient was seen by the sarcoma Multi Disciplinary Team very soon after the imaging suggested the diagnosis of sarcoma. The interval between the raised alkaline phosphatase noted in primary care and his first admission was 3 weeks, and he went on to the sarcoma service rapidly thereafter.” Source location Response from NHS England
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Concerns raised 1
Delays in endoscopy for routine referrals View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Rory Colin Williams · Prevention of Future Deaths report
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Report summary
Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in endoscopy for routine referrals
Wider context from the report “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:-
a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018.
b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why.
c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks.
d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023.
e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023.
f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known.
g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result.
” Source location Rory Colin Williams · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out capsule sponge endoscopy across the Health Board for suitable diagnostic circumstances.
Verbatim wording from the response “Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross-site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a temporary endoscopy unit at Ysbyty Gwynedd to provide additional diagnostic capacity.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess whether further outsourcing contracts are required for the new financial year.
Verbatim wording from the response “As an immediate mitigating action, a temporary endoscopy unit has been established at Ysbyty Gwynedd, planned to be operational from mid-March 2026 for an anticipated period of approximately five months. This facility has been introduced to increase diagnostic capacity and is expected to enable the delivery of in excess of 1,500 additional endoscopy procedures, supporting patients who have been waiting longer than intended for investigation. We are also progressing whether further contracts for additional outsourcing activity are required for the new financial year.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise referral, triage and prioritisation pathways across the Health Board.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Model whole-system capacity and demand to inform endoscopy access and service planning.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement interim capacity-enhancing measures to improve access while longer-term solutions develop.
Verbatim wording from the response “Actions underway to address this include the standardisation of referral and triage pathways across the Health Board, strengthened referral management (including the introduction of specialist nurse triage for all urgent cancer referrals) and prioritisation processes, whole-system capacity and demand modelling, and interim capacity-enhancing measures to improve access to care while longer-term solutions are developed.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue clerical and clinical validation of patients awaiting endoscopy to refine referral pathways.
Verbatim wording from the response “The Health Board has been working closely with national colleagues over the last three months to ensure both clerical and clinical validation of those awaiting endoscopy. Over 1000 referrals have been reviewed and approx. 40% have been removed from the waiting list either because it is felt that scope was not clinically indicated or that a further review or test may help decide whether the scope, or a different form of treatment, was needed. This work will be continued and is pivotal in the design of effective referral pathways.” Source location Response from Betsi Cadwaladr University Health Board
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29 Jan 2025 Carla Marie SMITH · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Excessive waiting times for urgent and routine referrals View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Carla Marie 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
Carla Marie SMITH died on 7 June 2023 after rapidly progressing metastatic endometrial cancer. The report identified missed opportunities in referral and use of the correct pathway, delays in laboratory results, and lengthy waiting lists. Concerns included the risk that patients may deteriorate while waiting and the lack of systems to monitor patients on routine or urgent waiting lists.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Excessive waiting times for urgent and routine referrals
Wider context from the report “1. During the course of the evidence, I heard from Consultants at two hospitals, and read evidence from others. The evidence I heard is that, at that time there were significant waiting lists, even for those on an urgent pathway . I heard that these issues persist and that, in relation to gynaecology referrals which was the subject of this inquest, where the expected waiting time would previously be 4-6 weeks for an urgent referral, one hospital has a waiting time of 18 weeks, the other 30 weeks (and 60 weeks for routine) . I was advised by one Consultant that they do not know how they can catch up with this backlog . I am aware that this is not a problem that is unique to just the two Trusts from whom evidence was heard.
2. The cause for concern is that some patients may significantly deteriorate while on such lengthy waiting lists. In some cases, this may mean that they lose some treatment options due to their condition advancing. This leads to a risk of future deaths.
” Source location Carla Marie SMITH · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restore the 18-week Referral to Treatment standard, with 92% of patients receiving treatment within that timeframe.
Verbatim wording from the response “commitment to reducing patient wait times and improving access to timely care. A key focus is restoring the 18-week Referral to Treatment standard, ensuring that 92% of patients receive treatment within this timeframe. Addressing the backlog and delays in gynaecology, which have faced increasing demand and performance challenges, is an important part of the overall return to constitutional standards.” Source location Response from DHSC
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17 Jul 2024 Lorraine Julia Proctor · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in cardiology specialist appointments View source
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Each statement is shown once, even when linked to more than one concern.
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Lorraine Julia Proctor · 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
Lorraine Julia Proctor had a history of cardiac health issues and was found unresponsive at home on 22 December 2023. A post-mortem identified acute myocardial ischaemia, coronary artery atheroma and ischaemic cardiomyopathy as the direct causes of death. The report raised concerns about lengthy cardiology waiting lists delaying specialist input for patients, although it was stated that an earlier appointment was unlikely to have changed Ms Proctor’s treatment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in cardiology specialist appointments
Wider context from the report “The inquest was told that there are significant backlogs for cardiology appointments not just in Greater Manchester but nationally . The reasons the inquest was told were multi factorial and included demand, resources available, covid backlogs and the impact of strike action.
As a consequence patients referred for first cardiology appointments from primary care are often waiting in excess of 40 weeks for a first specialist appointment and existing cardiology patients are also waiting similar periods of time for follow up appointments .
In Ms Proctor’s case the inquest was told that it was unlikely that there would have been a change to the treatment she was on even if she had been seen. However it was clear that this would not always be the case and patients requiring specialist input were not receiving it within the timescales that reduced the risk of complications and death .
” Source location Lorraine Julia Proctor · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Achieve the NHS Constitutional standard that 92% of patients wait no longer than 18 weeks from referral to treatment by the end of this parliament.
Verbatim wording from the response “I want to assure you that tackling waiting lists is a top priority for this government, as we work to get the NHS back on its feet. We have committed to achieving the NHS Constitutional standard that 92% of patients should no longer than 18 weeks from Referral to Treatment (RTT), by the end of this parliament.” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide additional regional and national support and scrutiny to trusts with the largest elective-care backlogs, including Manchester University NHS Foundation Trust.
Verbatim wording from the response “We recognise that it is unacceptable that some patients are waiting over 40 weeks for cardiology first appointments and too long for post treatment follow ups. NHS England (NHSE) is taking forward a programme of work to transform outpatient services, to ensure that patients can be seen more quickly and give patients more choice and flexibility about their treatment. The NHS and Department are also providing additional regional and national” Source location Response from DHSC
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work towards eliminating elective-care waits exceeding 65 weeks by September 2024, consistent with NHS England’s 2024–25 planning guidance.
Verbatim wording from the response “support and scrutiny to the most challenged trusts with the largest backlogs, including Manchester University NHS Foundation Trust, and continue to work towards the target in NHSE’s 24/25 planning guidance to eliminate waits of over 65 weeks by September 2024.” Source location Response from DHSC
Open published response
12 Mar 2024 Elizabeth Jane Brown · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in access to specialist immunology clinics View source
This report raised 1 other concern. 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.
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AI-generated summary
Elizabeth Jane Brown · 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
Elizabeth Jane Brown had severe respiratory disease and was diagnosed with mesothelioma, which was attributed on the balance of probabilities to asbestos exposure; she died at Stepping Hill Hospital on 23 January 2023. The inquest heard concerns about lengthy delays in immunology follow-up, linked to a significant national shortage of qualified and trained staff and high vacancy levels.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in access to specialist immunology clinics
Wider context from the report “The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January.
Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies. The position was not improving in terms of recruiting to vacant posts the inquest was told
” Source location Elizabeth Jane Brown · Prevention of Future Deaths report
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17 Oct 2023 Holly May Mullan · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Delays in access to gastroenterology and gynaecology specialist appointments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 5
Action
Implement the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Apply the Clinical Prioritisation Programme’s clinical-review expectations to waiting lists so patients with the most urgent conditions are reviewed first.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 30 October 2023. View source
Action
Transform outpatient services by expanding patient choice and control, promoting patient-initiated follow-up, safe discharge with safety-net advice, and reduction of missed appointments.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source
Action
Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023. View source See 2 more actions
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Holly May Mullan · 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
Holly May Mullan had longstanding severe abdominal pain and experienced long waits for NHS appointments with gynaecologists and gastroenterologists. She was found attached to a ligature on 7 May 2023, and the inquest heard that prolonged waiting times were causing distress, delays in diagnosis and delays in treatment for people with significant health conditions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in access to gastroenterology and gynaecology specialist appointments
Wider context from the report “The inquest heard evidence of the distress caused to Holly and the impact on her health by the long waits to be seen by gastroenterologists and gynaecologists within the NHS . The evidence heard was that post-Covid, the waiting times to be seen in both specialties unless the referral was on the two-week cancer wait had grown significantly across England . As an illustration the inquest was told that pre-Covid, the average wait for a routine gynaecology referral was 18 weeks. Now in England the wait was often in excess of 12 months. Even an urgent referral would often involve a wait of over 40 weeks. This was leading to delays in diagnosis and treatment even in those with significant/severe health conditions.
” Source location Holly May Mullan · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.
Verbatim wording from the response “NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.
Verbatim wording from the response “The GIRFT Further Faster Programme is also specifically looking at eradicating long waiting times from referral to treatment (RTT), in 16 different specialties. The specialties of Gastroenterology and Gynaecology both involved in the Further Faster Programme and have made good inroads into reducing long RTT waiting times in the first cohort of Further Faster Trusts (25 Trusts taking part), compared to the non-further faster Trusts. Of the 16 specialties involved in this programme, gastroenterology has shown the greatest impact (39% difference, as non-further faster trusts’” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Apply the Clinical Prioritisation Programme’s clinical-review expectations to waiting lists so patients with the most urgent conditions are reviewed first.
Verbatim wording from the response “As part of the further NHS response to COVID-19, NHS England introduced the Clinical Prioritisation Programme. This sets out an expectation of clinical review of waiting lists, to enable patients with the most urgent conditions to be reviewed first based on the information available (such as urgency indicated at referral or decision to admit, procedure type, specialty, and length of time that the patient has been waiting for treatment). The guidance was developed with the Academy Of Medical Royal Colleges.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Transform outpatient services by expanding patient choice and control, promoting patient-initiated follow-up, safe discharge with safety-net advice, and reduction of missed appointments.
Verbatim wording from the response “The NHS is changing how it delivers outpatient services so that patients can be seen more quickly and can access and interact with services in a way that better suits them. We are giving patients and carers more control and greater choice over how and when they access care. We have recommended more use of patient initiated follow up (PIFU) pathways, which help empower patients to book their own follow-up care as and when they need it. We are encouraging services to discharge patients as soon as this is appropriate, with safety net advice, to reduce unnecessary follow up appointments. This allows those patients who do need to access appointments to be seen more quickly. We are helping services to reduce the number of missed outpatient appointments (did not attends or DNAs) to make the best use of all available appointments.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.
Verbatim wording from the response “As part of outpatient transformation, we are encouraging and enabling access to earlier expert advice through triage of referrals and by greater use of advice & guidance (A&G) or advice & refer (A&R) services. This allows patients and GPs to get the benefit of expert advice and treatment much earlier in the patient pathway. Patients who do not need to be seen in outpatients can continue to be safely managed in primary care, following specialist advice, or may be diverted direct to test where appropriate to facilitate an earlier diagnosis. This allows those that do not need to be seen in clinic to get access to clinic in a much shorter timescale and will help reduce referral to treatment times for all patients.” Source location Response from NHS England
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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 cannot investigate the relevant waiting-list pathway without further particulars.
Verbatim wording from the response “It is not clear from your Report or from subsequent questions to your office if Holly received any diagnosis for the pain she was experiencing or if she was eventually seen by NHS gynaecologists or gastroenterologists. If she was on an admitted waiting list, but instead waiting for outpatients service her referral should have been triaged, although NHS England are not able to investigate this without further particulars. You may wish to contact the Trust to obtain further information.” Source location Response from NHS England
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3 Feb 2022 Mark Jones · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Backlog in standard referrals causing prolonged outpatient waiting times View source
This report raised 2 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.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Backlog in standard referrals causing prolonged outpatient waiting times
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
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25 Apr 2017 Linsay Bushell · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Poor coordination and delay in referral review for specialist placement View source
This report raised 15 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.
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Linsay Bushell · 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
Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Poor coordination and delay in referral review for specialist placement
Wider context from the report “The Court heard evidence that 40% to 50% of mentally disordered female patients suffered from EUPD rather than mental illness and yet there was no provision or priority for therapeutic psychological services to be commissioned in the NHS England Area.
The Jury found:
Para 3
1. Linsay Bushell was certified as having died on the evening of 13th October, 2014. at the Royal Liverpool University Hospital.
2. Linsay Bushell came by the fatal event that caused her death at 20.20 at room 2 on the Brunswick Ward at the Broad Oak Unit on 13th October 2014.
3. The medical cause of Linsay's death was Asphyxia due to Compression of the Neck due to Ligature Strangulation.
4. Linsay put herself in the position in which she was found however her intention was unclear.
5. At the time of her death and for most of her adult life, Linsay had suffered from a form of mental disorder namely an unstable borderline personality disorder.
6. The real and imminent risk of self-harm or suicide was recognised during Linsay's care at the Broad Oak Unit in the time leading up to her death.
7. The risk was managed adequately and effectively during Linsay's period as an in-patient.
8. The jury accept the admissions of Mersey Care NHS Foundation Trust and adopt the findings that the Trust has made.
a. In the Trust Position Statement
Mersey Care considers the death of any service user with the utmost seriousness and care. As an organisation it is committed to providing a high standard of care to service users generally. If, in connection with any patient under its care, mistakes have been made whether in the form of individual errors or as a result of system or structural defects, then the Mersey Care Trust Board is committed to uncovering those errors, correcting them and learning lessons from them.
2. Following the death of Linsay Bushell on 13th October 2014, Mersey Care instigated an investigation into her death, including the wider circumstances of her death, to find out whether there were shortcomings in the care provided to Linsay and, if so, devise ways of improving practice. That investigation was an internal review and root cause analysis by a multi-disciplinary panel which included an external medical reviewer. Its Terms of Reference were agreed by the Trust Board and were deliberately wide so as to pick up deficits in care or indeed examples of good practice throughout Linsay's involvement with the Trust and so enable as deep a learning exercise as possible in what was acknowledged to be a complex clinical picture. The review panel considered relevant documents and interviewed members of staff and the investigator's report was provided to Mersey Care Trust Board in December 2015.
3. Following the internal investigation, the Trust Board instructed ████████ the Chief Operating Officer of the Local Services Division to consider the report of the internal investigation and undertake her own review and appraisal of the circumstances of the death. She was also instructed to devise a workable and practical strategy to address the issues which were raised by the internal review and her own consideration of the material.
4. The Trust is committed to transparency and accountability. The purpose of this Position Statement is to advise the Court and Linsay's family of the Trust's response to the work which has been undertaken internally by the Trust and of the approach which will be taken to the forthcoming inquest into Linsay's death. It is hoped that, by doing so, the Court's case management task in respect of the forthcoming inquest will be facilitated; also importantly that Linsay's family will be reassured by their understanding that an approach which is consistent with the conclusions of the internal review of the death is to be adopted at the inquest.
5. The conclusions of the internal review include some examples of good or notable practice and many areas where the service or care provided to Linsay fell short of the desired standards. Following concerns raised by a member of staff, the Review Team considered the contents, including the conclusions, of the internal review undertaken. Having done so, the Review Team adheres to the conclusions which were expressed in the report. The Trust Board fully acknowledges that mistakes had been made in Linsay's care when she was a resident on Broad Oak Unit and that these mistakes afforded Linsay the opportunity to ligature on 13th October 2014. The Trust accepts responsibility for Linsay's death. Whilst understanding that no apology will fully assuage the feelings of Linsay's family and those who were close to her, the Trust nonetheless offers that apology. It is made with sincerity.
6. The review panel considered that Linsay's psychiatric condition was complex. Her condition fluctuated in response to stressors such as bereavement and illicit drug use. However, a main theme to emerge from the internal review panel report was the failure of the Trust to provide Linsay with a service that was psychologically driven at all levels of care. The Trust accepts this criticism.
It is accepted that psychology interventions were not available on a consistent basis throughout Linsay's residence on the Unit and that ward staff were inadequately supported in their provision of such care and treatment.
a. Whilst an attempt to understand the motivation for self-harming behaviour is apparent from the Acute Care Plans (which were not available to the panel) the Trust accepts that this was inadequate. The Trust also accepts that the record keeping and standard of documentation was inadequate so that a more detailed picture of Linsay's self-harming behaviour and its triggers was not available. As a result, staff were hampered in considering the best ways of limiting and controlling Linsay's self-harming behaviour.
b. Whilst understanding that patients suffering from Personality Disorders may present a complex management problem, a focused and co-ordinated approach to finding the most appropriate establishment to meet Linsay's needs was not adopted. It was recognised that Brunswick Ward did not meet Linsay's short or long-term needs. Although efforts were made by the Care Co-ordinator to locate the most appropriate placement for Linsay, funding was not immediately available. This had the effect of causing Linsay distress and disappointment. The Trust accepts this criticism.
c. Staff were not sufficiently trained and supported in their understanding of Emotionally Unstable Personality Disorders and the high suicide rate associated with this condition particularly during long term hospital stays. Again, the Trust accepts this criticism.
7. Further themes to emerge from the internal review included: the lack of implementing a co-ordinated approach to checking patients after handover; that handover documentation was scant; that documentation of observation levels was insufficiently clear; that there were limited interventions regarding substance misuse and its effect on Linsay's self-harming behaviour and that ward management needed greater support. All of these observations and criticisms are accepted by the Trust.
8. ████████ has been tasked with reviewing Linsay's care during her residence on Brunswick Ward and reviewing the conclusions of the internal report. She is involved in the wider Trust initiatives which include reducing the risk of suicide by patients and enhancing the understanding and treatment of those patients who suffer from Personality Disorders. She has set out the steps which have been taken in her statement. The key points are as follows:
a. Given the wide understanding that those suffering from Personality Disorders are best managed in the community, a Personality Disorder Hub has been established in the community. This is now led by ████████ a Consultant Psychiatrist in Psychotherapy, and is intended to co-ordinate and manage the care of patients with Personality Disorders within the community. The objective is that, where possible, admissions to hospital are kept short, or avoided altogether. This involves close and collaborative working by all of those involved in the patient's care. This is facilitated by the PD Hub.
b. Case managers have been recruited and assigned to service users who attend the emergency services regularly (as a consequence of self-harming behaviour). These case managers work closely with the PD Hub and focus care on the individual. The care given is psychologically based. It is targeted at helping the patient to devise strategies to limit self-harming behaviour.
c. Borderline Personality Disorder Guidelines have been devised which stipulate that meetings of professionals should take place in complex cases and a specific Extended Care Plan should anticipate and considers care both in the community and in inpatient units. The objective is to provide a coherent and co-ordinated plan of care which is tailored to the particular needs and challenges posed by the particular patient.
d. Nursing staff have received training in Personality Disorders. Complex Case discussions take place on all wards. This is intended to enable multi-disciplinary team discussion between professionals in particularly challenging cases.
e. A daily Bed Management system has been introduced which, amongst other objectives, is intended to ensure that patients with Personality Disorders are discharged back into the community with minimum delay and with an appropriate support package.
9. Although ████████ describes in her statement the various responses which have been made by the Trust to improve the management of patients with Personality Disorders, the individual elements are intended to work as only part of an integrated model. The strength of the structure lies in its overarching objective of transforming the approach generally to meeting the needs of those with Personality Disorders, recognised as presenting a particular set of challenges to any healthcare organisation.
10. ████████ also addressed in her statement the further steps which have been taken to support staff in complying with Trust policies, including the Care Programme Approach, observation levels, suicide prevention and training, record keeping and shift handover documentation. Regular audits for compliance and ongoing support is undertaken. There has been a review of leadership roles within the Unit generally including Brunswick Ward and support and guidance for those occupying a leadership role is regularly provided.
11. As ████████ has stated, although much has changed since Linsay's death, there is no room for complacency. She and others within the Trust will continue their work and undertake a regular evaluation of service levels.
12. It is hoped that Linsay's family are encouraged in their understanding that the Trust have taken Linsay's death very seriously indeed. Lessons have been learned. Her death has been a catalyst for change for the better.
b. In the implementation of Lessons learnt the Trust further accepts
1. The review team identified this as "a very complex case" and noted that "it is unclear whether or not LB harmed herself with a view to achieving death or in an effort to gain help from staff which had happened on many occasions before during her in-patient stay".
a. The review team reached a number of critical conclusions relating to the care which Linsay received during the course of her involvement with the Trust. The principal conclusions were as follows:-
b. Limited understanding and analysis of self-harming behaviour. The review team noted that Linsay was described as undertaking self-harming behaviour on many occasions and that her 'ligaturing' was used in the notes in a generic sense with no specific details given on many occasions. The review team concluded that despite repeated attempts at self-harm with the same behaviour, insufficient effort was made to look at this particular risk. They also concluded that the notes did not pick up exploration of the reasons behind many self-harm attempts. Instead, they thought it was generally assumed that Linsay's self-harming behaviour was as a result of either drugs or some form of stress or 'loss' and that a more detailed exploration of her episodes of self-harm might have proved useful in terms of developing preventative strategies. Linsay did not have a "safety plan" as this was not Trust policy at the time. However, she did have a Care Plan.
c. Failure to implement a co-ordinated approach towards checking the safety of patients following handover. Staff told the reviewers there was no co-ordinated approach to allocating tasks on the night in question. On that night there was no formal "walk around" undertaken by a qualified member of staff as required by policy. The review team concluded that it was essential that generic safety systems such as the handover check are implemented very robustly as they are the alternative to individual observations being used which in this case were thought to have a negative effect on Linsay.
d. Poor quality of handover information. The handover notes were frequently scant in content. There was no standard template as to what should be included in handover. The review team was unclear how the nursing handover was quality controlled. On just one occasion it was mentioned in handover that Linsay had ligatured during the day but despite the frequency of this behaviour the handover notes did not capture this at all.
e. Confusion about observation levels. There were occasions when it was unclear what level of observation Linsay was on. On the day of the incident staff told the reviewers they were informed that Linsay had been on leave with a member of staff and that it had gone very well, that she was settled and had just had a take-away meal. There was no discussion as regards any risk that Linsay may have been at, taking into account previous behaviour after leave. Recording of changes in observation levels were frequently unclear.
f. No process to monitor the completion of CPA documentation. The review team could not identify the processes that were in place to ensure that all patients had an up to date risk management plan and care plan hence they found that the plans in place for Linsay were not current although Linsay did in fact have a current care plan.
g. Limited content and poor quality of documentation. Documentation of observation levels was not as clear as it should have been and given her very high risk it was important to document any observation changes and the reasoning behind this. This might help build up a picture of the best way of mitigating any potential risk from any form of self-harm, particularly with that associated with ligaturing. It would also help staff adopt a more 'psychological' approach to care rather than using physical intervention like high observation levels or PRN medication if 'agitated', the latter of which was similar in a way to her 'substance misuse. The review team noted that staff did spend a lot of time talking to Linsay but the notes did not capture any questioning as to why she had tried to self-harm at a particular time.
h. Limited interventions regarding substance misuse as an inpatient. Linsay's highest risk of suicide seemed to be in the aftermath of substance misuse. Whilst this was commented on, specialist measures to try and mitigate it were not put in place. The addiction case worker did not attend multi-disciplinary team meetings whilst on the ward, though they did see Linsay whilst she was an inpatient in Childwall Brook Nursing Home. The reviewers noted that the care appeared to be fragmented in that different parts of the services did not plan or deliver the care that was needed together.
i. Poor coordination of referral to a specialist provider . The team pursued a variety of specialist placements in an attempt to meet Linsay's care needs going forwards. One of them, Cambrian Care, undertook an assessment and accepted Linsay as they felt that they had the ability to provide her with the appropriate care required. When the funding was requested it was rejected by the Clinical Commissioning Group (CCG). It was at this time that the funding of Out of Area Placements was being changed with the Trust being given the delegated responsibility for allocating resources on behalf of the CCG. Consequently Linsay's future needs were re-assessed and internal placements were considered in the Trust's own services. The review was completed a short time before Linsay's death, and recommended that an Out of Area specialist placement should be supported. The review team felt that the whole process of having Linsay assessed externally and then the process being stopped would have raised her expectations inappropriately. The significant delay in undertaking a review process was felt by the review team to have kept Linsay in an area that was recognised as not being able to meet all her short and long term needs.
j. Ward Management. Brunswick ward was a very busy admission ward. The Ward Manager did not have a background in leading such a ward nor did the Modern Matron who came from a community background. This meant that senior challenge and specific clinical guidance for staff was not available. During interviews it was suggested that there had been some friction between nurse management on the ward that may have contributed to a background of poor team working. The review team advised that it was important staff were led by experienced managers who understand both the management processes and the clinical area they are responsible for.
k. Transfer of Patients from one organisation to another. The review team identified and amongst staff that patients could not be transferred from one organisation to another until they were "stable". This was impracticable for cases like Linsay's as she was rarely, if ever, stable. She lived in an area inaccessible to her treating psychiatry service when she lived in Kensington whilst remaining under 5 Boroughs Partnership NHS Foundation Trust's care. The review team concluded that regular engagement with local Mersey Care services might have avoided Linsay's final admission.
l. Lack of implementing a clear care pathway. Linsay had a diagnosis of Emotional Unstable Personality Disorder which is associated with a high suicide rate long-term. This is particularly increased during extended in-patient stays. Staff stated during interview that they had not had training related to self-harming behaviour or in the care of people with an Emotionally Unstable Personality Disorder. The reviewers could not identify a clear pathway that was being followed to care for Linsay which took into account her complex needs. Whilst staff appeared to have worked hard at building a relationship up with Linsay the review team concluded that it was generally at a superficial level. The review team noted that the Trust had a Borderline Personality Disorder strategy and guidance but could not find that it was implemented or understood by staff. The review team recognised the national view is that admissions for people with a Borderline Personality Disorder are often counterproductive to improving the mental state of a patient and at worst contribute to difficulties and worsening of the condition. How and when clinicians feel able to take managed and considered “positive” risks is important. How these issues are factored into an extended care plan and the support that clinicians can receive on these cases needs to be clear and thought through by the Trust. The review team are aware that this work was on going within the organisation.
m. Lack of specialist psychological work/guidance to staff. The review team found that specialist interventions were not available on a consistent basis. The review team found that there was inconsistent availability of psychology on the ward environment during the last period of Linsay's admission. The review team were told that Linsay was not amenable to psychological interventions and had tried different modalities in the past. It was a concern that whilst Linsay may not have wanted or been able to avail herself of therapy the overall strategy of care should have been directed and guided from a more psycho-therapeutic perspective.
2. The review team could not identify one specific root cause but felt that the contributory factors interacted together to create a situation whereby Linsay remained distressed on the ward, with limited up take of psychological therapy to help reduce the distress seemingly enhanced by her recent losses. The staff clearly tried hard to work with her but with limited knowledge. There was a sense of fragmented care in that specialist services such as those offered by the addiction team were not engaged in the ward discussions despite Linsay engaging with them during her short stay at Childwall Brook Nursing Home. The period to identify a suitable placement for Linsay seemed overly protracted and seemed to focus thoughts on an external answer to the escalating situation.
Discontinuity of Care/Management of Care
3. The Trust has done a lot of work looking at how to develop the service it offers to service users with a diagnosis of personality disorder. It has developed Guidelines for the management of these individuals and established a Personality Disorder Hub (PD Hub) headed by ████████ a Consultant Psychologist, in November 2014. These Guidelines are produced at pages 311 - 355 of the Inquest Bundle B.
4. The Trust's Borderline Personality Disorder Guidelines advise that in complex cases there should be a meeting of professionals followed by the development of a specific Extended Care Plan (ECP). The ECP starts with a formulation/summary of the history and care provided, and then describes the type of care that should be provided in different settings including inpatient units.
5. Evidence suggests that prolonged or repeated hospital admissions are not helpful for service users with a diagnosis of personality disorder. The PD Hub aims to keep admissions to hospital as short as possible and to avoid them altogether where appropriate. The Trust has recruited individual psychologists and nurses trained and qualified in managing patients with a personality disorder diagnosis to work as case managers for this group of service users. They are responsible for managing the care of the most complex service users regardless of where the service user goes and thus are able to provide continuity of care and work with other care teams to provide consistency of approach.
6. The team initially identified 40 service users who attended A&E on a regular basis and allocated these to the 4 case managers then in post so that each case manager was responsible for 10 service users. Given the success of this work more case managers have been recruited so that the most complex service users who have increased need now have a specialist case manager.
7. The case managers are focussed care for the individual. The approach to care is psychologically based and will include the case manager working with the service user to look at their risk taking and what triggers it. They will then work with the service user to develop strategies to enable the service user to cope with these triggers. Triggers may include memories of past abuse.
8. The Trust is working towards extending the recently introduced day service available for people with personality disorder as part of our evidenced based PD pathway.
9. The aim is to help the service user to manage their condition differently and thus avoid hospital admission if possible.
Risk Assessment/Care Planning
10. Linsay's mental state, level of distress, reported symptomology and self-harming or suicidal behaviour fluctuated quite markedly during her admission. I accept that there was an unstructured approach to reviewing and planning interventions with Linsay which meant there was no collaboratively developed understanding of her risk.
11. Staff are expected to reassess the risks following each ligature incident and episode of self-harm and document the fact that an assessment had taken place and the conclusions reached. Such reviews ought to have included a detailed exploration of Linsay's mental state, her thoughts and feelings and the level of observation she required.
” Source location Linsay Bushell · Prevention of Future Deaths report
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19 Feb 2016 Geoffrey John MOYSE · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Delays in referral to appropriate specialist services View source
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Geoffrey John MOYSE · Prevention of Future Deaths report
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Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in referral to appropriate specialist services
Wider context from the report “(1) Please see the attached letter dated the 19th December 2014 which explains the system which was put in place by the CCG.
Please refer to Part 3 of the attached Record of Inquest to learn what happened in Mr Moyse’s case.
It is clear to me from the evidence I heard at the Inquest that there was a huge delay in referring him (its right to say that some of that delay was due to Mr Moyse being unable to help speed the process up). Nonetheless, it took eight months from referral to seeing the appropriate Surgeon and I should imagine a referral direct to Digestive Diseases would have been substantially quicker than that .
There was no understanding it seems by the people involved in the arrangements that it was probably possible to try and short circuit them. For example, why did the Consultant Gastroenterologist not contact the colorectal clinic himself or even copy his letter and his histology report sent to the GP on the 29th June 2015?
Why did BICS, who were sent a copy of the histology report, not forward this to anyone else e.g. the colo-rectal clinic to see whether it would produce the urgent result which the GP was seeking to achieve?
Could the GP have done a two week referral at the very beginning? Would that have come within Code 2 on the letter of the 19th December 2015? If he had, perhaps the whole system would have worked.
One of the problems in existence appears to be that because the initiative involves private hospitals, some private hospitals will use their own histo-pathologists to analyse results of procedures such as colonoscopies instead of using the National Health laboratories. This means that the results do not automatically feed in to the local NHS system. Surely it would be possible to insist that all x-ray results, MRI scans, CT scans, histopathology reports etc. etc. which arise in this way as part of an NHS initiative involving the private sector must be transmitted back into the NHS system at the earliest possible opportunity.
It just seems to me that this system broke down because these processes seem to work with any reference to a joined up approach and the person who suffers is the patient.
In this case I was eventually satisfied that this did not adversely affect the outcome with Mr Moyse but certainly it meant that the whole process for him was hugely delayed and he was left unwell, undiagnosed and untreated for far, far too long. I would like to see a complete review of this process and I am sure that Mrs Moyse would be happy, suitably anonymised, if Mr Moyse’s case could be used to ensure that this does not happen again to another patient where this delay might have been fatal on its own.
” Source location Geoffrey John MOYSE · Prevention of Future Deaths report
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PFD Monitor interpretation Implement changes to improve the effectiveness of abdominal surgery and medicine services.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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PFD Monitor interpretation Increase abdominal surgery staffing by appointing three surgical consultants.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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PFD Monitor interpretation Appoint an additional colorectal and emergency surgeon.
Verbatim wording from the response “The Trust has been very conscious of the considerable difficulties in providing timely abdominal surgery appointments. A new Clinical Director of Abdominal Surgery and Medicine took up post in December 2015, and has already implemented several changes to improve the effectiveness of this service. Since the death of Mr Moyse, three new surgical consultants have taken up posts in the department and another Colorectal/Emergency surgeon is due to start in June 2016. We anticipate there will no requirement for Locum Consultants from June 2016.” Source location Moyse-Response
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PFD Monitor interpretation Develop an overarching Referral to Treatment recovery plan covering CCG-owned and provider actions.
Verbatim wording from the response “You identified that there had been a delay in Mr Moyse receiving assessment and treatment within secondary care because of prolonged waiting times within the Digestive Diseases department at Brighton & Sussex University Hospitals (BSUH). As you know there remain considerable and long standing challenges regarding waiting time performance within BSUH for the NHS constitutional target of 18 weeks from referral to treatment. The CCG is working closely with BSUH and primary care in the city with the aim of reducing the waiting times for secondary care whilst improving the patient experience and reducing the risk of any patient experiencing harm. The CCG has developed an overarching Referral to Treatment recovery plan which includes both BSUH internal actions and those owned by the CCG.” Source location Moyse-Response
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PFD Monitor interpretation Monitor the effects of extended secondary-care waiting times on patient care and experience through monthly quality review meetings.
Verbatim wording from the response “In addition to these actions, the CCG's Quality Team closely monitor the impact on patient care and patient experience of the extended waiting times for referral to treatment within secondary care. The CCG chair the Quality Review Meeting with BSUH held monthly where extended waiting times and their impact is monitored. The CCG has received a Serious Incident report from BSUH related to the extended waiting times for treatment and the lessons from this report have been incorporated within the overarching programme of work. The CCG is also facilitating a clinically led scrutiny panel reviewing those patients care who have waited longer than 52 weeks for treatment following referral.” Source location Moyse-Response
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PFD Monitor interpretation Incorporate lessons from the serious-incident report on extended treatment waiting times into the overarching programme.
Verbatim wording from the response “In addition to these actions, the CCG's Quality Team closely monitor the impact on patient care and patient experience of the extended waiting times for referral to treatment within secondary care. The CCG chair the Quality Review Meeting with BSUH held monthly where extended waiting times and their impact is monitored. The CCG has received a Serious Incident report from BSUH related to the extended waiting times for treatment and the lessons from this report have been incorporated within the overarching programme of work. The CCG is also facilitating a clinically led scrutiny panel reviewing those patients care who have waited longer than 52 weeks for treatment following referral.” Source location Moyse-Response
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How this respondent action was interpreted
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PFD Monitor interpretation Conduct a clinically led scrutiny review of patients waiting more than 52 weeks for treatment.
Verbatim wording from the response “In addition to these actions, the CCG's Quality Team closely monitor the impact on patient care and patient experience of the extended waiting times for referral to treatment within secondary care. The CCG chair the Quality Review Meeting with BSUH held monthly where extended waiting times and their impact is monitored. The CCG has received a Serious Incident report from BSUH related to the extended waiting times for treatment and the lessons from this report have been incorporated within the overarching programme of work. The CCG is also facilitating a clinically led scrutiny panel reviewing those patients care who have waited longer than 52 weeks for treatment following referral.” Source location Moyse-Response
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PFD Monitor interpretation Issue a performance notice and closely monitor the Referral Management System provider’s performance and contract.
Verbatim wording from the response “Since Mr Moyse sadly passed away there has been a change in the delivery of the Referral Management System within the City which is now provided by Optum. As you may be aware there have been initial difficulties with the current provider coupled with national challenges relating to the electronic referral system for primary care to refer to secondary care. The CCG has been working very closely with the new provider over recent months to ensure an appropriate level of service. Actions taken to date have included issuing a performance notice to the provider and close performance and contracting monitoring. The CCG continues to work closely with the provider to ensure patients are offered choice as to where they wish to receive secondary care treatment.” Source location Moyse-Response
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How this respondent action was interpreted
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PFD Monitor interpretation Work with the Referral Management System provider to ensure patients are offered choice of secondary-care provider.
Verbatim wording from the response “Since Mr Moyse sadly passed away there has been a change in the delivery of the Referral Management System within the City which is now provided by Optum. As you may be aware there have been initial difficulties with the current provider coupled with national challenges relating to the electronic referral system for primary care to refer to secondary care. The CCG has been working very closely with the new provider over recent months to ensure an appropriate level of service. Actions taken to date have included issuing a performance notice to the provider and close performance and contracting monitoring. The CCG continues to work closely with the provider to ensure patients are offered choice as to where they wish to receive secondary care treatment.” Source location Moyse-Response
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PFD Monitor interpretation Referral locations and access to relevant imaging or histology are determined by Clinical Commissioning Groups, not the Trust.
Verbatim wording from the response “The Trust recognises that fragmentation of healthcare increases the opportunities for delays, breakdown in communication and potential compromise of effective patient care. However, the local NHS health economy is bound by the decisions of Clinical Commissioning Groups as to where patients may be referred for investigations and treatment, and how any imaging or histology which may be relevant to multidisciplinary team discussion is made readily available. Private providers of services are at liberty to choose to which laboratory specimens are submitted for reporting. This fragmentation is increasing. It is extremely disappointing that since January 2016, some histology work which used to be sent to the laboratory of this Trust from a local private hospital is now being sent elsewhere, and other privately run organisations were already doing this.” Source location Moyse-Response
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PFD Monitor interpretation The referral service swiftly handled referrals, followed its protocols and demonstrated best practice in managing the patient’s care.
Verbatim wording from the response “████████ (the Joint Clinical Lead for the service at the time) has reviewed our involvement with Mr Moyes and I have attached an investigation report which I hope addresses the matters of concern that you have identified. In particular it found that the Referral Management Service swiftly handled Mr Moyes’ referrals, actively sought options and encouraged him to be seen as soon as possible at a convenient location of his choice. Our records show that our Patient Care Advisor was concerned about his decision to wait longer for treatment and this was shared with his GP. Our investigation also showed that the pathology report and all the other referral documents dated the 26th July were faxed to the Nuffield on the 5th August, at the request of the patient and the GP. In addition an urgent referral was sent to Royal Sussex County Hospital.” Source location G-moyse-Response_Redacted
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25 Feb 2014 Stephen John PALMER · Prevention of Future Deaths report Brighton and Hove
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Concerns raised 1
Delays in surgical review after referral View source
This report raised 10 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.
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Stephen John PALMER · 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 John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in surgical review after referral
Wider context from the report “(1) Delay in being seen both by Nursing Staff and Doctors in A & E.
Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013.
Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit.
” Source location Stephen John PALMER · Prevention of Future Deaths report
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Includes excessive or unsafe waits for specialist assessment after referral, including delays in referral triage, specialist appointment access or progression to the appropriate specialist service, where the referral pathway itself is the bounded concern.
