Recurring concern

Failure to identify and refer patients needing specialist respiratory input

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First reported 30 Mar 2015•Latest report 30 Jan 2023

Definition

What this concern includes

Includes failures to identify a respiratory component, notify or seek advice from respiratory teams, or refer patients for clinically required specialist respiratory input.

Not included

  • Excludes failures in respiratory assessment, diagnosis or treatment after the respiratory team has been appropriately notified.
  • Excludes generic clinical communication, handover or referral failures without an explicit respiratory-team identification, notification or referral connection.
  • Excludes failures involving other specialist teams or non-respiratory conditions unless the assertion directly concerns the respiratory-team notification process.
  • Excludes respiratory staffing or on-call-cover shortages where the notification or referral process itself is not deficient.
  • Excludes deficiencies in respiratory monitoring or treatment that do not involve identifying and bringing the patient to the attention of the respiratory team.
Reports
7

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2015–2023

First to latest report issue date

Stated actions
6

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 England4
National Institute for Health and Care Excellence2
Department of Health and Social Care1
Epsom and St Helier University Hospitals NHS Trust1
Farnham Medical Centre1
Jeesal Akman Care Corporation Limited1
Jeesal Holdings Limited1
Jeesal Residential Care Services Limited1
NHS North East and North Cumbria Integrated Care Board1
Norfolk and Norwich University Hospital1
Royal Cornwall Hospital1
South Tyneside and Sunderland NHS Foundation Trust1
the Newcastle Upon Tyne 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. Cornwall and Isles of Scilly

    AI-generated summary

    Felice Eileen Grace Banfield · 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

    Felice Eileen Grace Banfield was admitted with a painful knee and required non-invasive ventilation, but there was a lack of clarity about where and when this could be provided. She was not brought to the attention of respiratory clinicians, deteriorated with mixed respiratory and metabolic acidosis and an acute kidney injury, and died despite treatment. The principal concerns were failures concerning access to non-invasive ventilation, recognition of respiratory risk and deterioration, and provision and monitoring of adequate food, fluids and continuity of care.

    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 identify admitted patients with a respiratory component and bring them to the attention of the respiratory team

    Wider context from the report

    “A patient admitted into RCHT with a respiratory element to her underlying condition was not brought to the attention of the respiratory team. The presenting complaint was not of a respiratory nature and so the challenge appears to be to identify those patients with multiple co-morbidities, one of which has a respiratory component, particularly where the patient is not on a respiratory ward. ”

    Source location

    Felice Eileen Grace Banfield · 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

    Use PAS alerts and the RADAR report to identify NIV patients admitted outside respiratory wards.

    Verbatim wording from the response

    “Based on the learning from this case, where patients whose primary reason for admission is not a respiratory element, but because of the specialist care some respiratory patients may require, for example, as in this case NIV; it was decided that it would be useful to have a way of quickly identifying these patients to the respiratory clinical nurse specialist team when the patients are not accommodated on a respiratory ward.”

    Source location

    Response from Royal Cornwall Hospital
    Page 3 · response
    Published 30 January 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

    Have Respiratory CNS staff review the RADAR report daily, contact identified wards and offer support.

    Verbatim wording from the response

    “The report in RADAR has been shared with the Respiratory Matron and Respiratory Clinical Nurse Specialists (CNS). The expectation of the Respiratory CNS team is that they will review the RADAR page daily, contact the ward where the patient has been identified as admitted and offer any support that may be required, they will also ensure the ward has the contact details of the CNS so that they can be contacted if there is any need for their input.”

    Source location

    Response from Royal Cornwall Hospital
    Page 3 · response
    Published 30 January 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

    Patients without concerns about a known respiratory co-morbidity need not be managed on a respiratory ward; existing referral arrangements apply if concerns arise.

    Verbatim wording from the response

    “Not every patient presenting to the hospital with known co-morbidities will need to be cared for on the speciality ward for their known co-morbidity. If there are no concerns related to their underlying condition, they would be cared for on the appropriate ward for their primary presenting issue. If during the admission the underlying condition did give cause for concern, the patient would be referred to the appropriate speciality via the Maxims system. There is a space on the referral to leave your contact details and if for any reason the referral is rejected, the rejecting clinician can notify the referrer if these details have been completed.”

    Source location

    Response from Royal Cornwall Hospital
    Page 3 · response
    Published 30 January 2023

    Open published response

  2. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    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 notify the respiratory team of emergency department attendances

    Wider context from the report

    “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. 3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems ”

    Source location

    Ben Buster KING · 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

    Failure to communicate prior emergency department attendance to the respiratory consultant

    Wider context from the report

    “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. 3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems ”

    Source location

    Ben Buster KING · 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

    Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.

    Verbatim wording from the response

    “That said, the importance of effective communication is clearly recognised and to promote good quality handovers the Respiratory team now hold a daily morning report meeting, attended by all the on-call specialities. At these meetings cases are discussed and referred to other specialities as appropriate.”

    Source location

    2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
    Page 1 · response
    Published 23 July 2021

    Open published response

  3. East London

    AI-generated summary

    Kalila Elizabeth Griffiths · 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

    Kalila Elizabeth Griffiths, who had complex medical conditions including asthma, developed worsening breathing problems in January 2019 and died on 1 February 2019 from a pulmonary embolism, with asthma contributing to her death. The report states that she was discharged from hospital on 19 January despite severe respiratory deterioration and required observation and respiratory physician assessment. Concerns included the management of asthma patients nationally, inconsistent clinical guidelines, uncertainty over which guidelines should be used for acute asthma attacks, and insufficient 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 refer eligible asthma patients to a specialist asthma service

    Wider context from the report

    “(1) Factual and expert witnesses gave evidence that there are concerns about the management of asthma patients within the NHS as a whole. The National Review of Asthma Deaths (“NRAD”), was published in 2014. This was five years before the care provided to Kalila and six years before the Inquest. Notwithstanding the length of time that has passed, the Inquest heard that eighteen of the nineteen recommendations set out in the NRAD report have not been implemented. The recommendations of importance in this case were: • Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids in the previous twelve months. • Follow-up arrangements must be made after every attendance at an emergency department or out of hours’ service for an asthma attack. • Secondary care follow-up should be arranged after patients have attended the emergency department two or more times with an asthma attack in the previous twelve months. • Electronic surveillance of prescribing in primary care should be in place to pick up too many or too few preventer inhalers. ”

    Source location

    Kalila Elizabeth Griffiths · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. London (East)

    AI-generated summary

    Sophie Holman · 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

    Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist 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

    Failure to consider referral to a specialist respiratory or severe asthma service

    Wider context from the report

    “2) There was: a. No coordinated record of these occasions b. No analysis of the frequency or circumstances of these events c. No analysis of the underlying chronic asthma condition d. No appreciation of the risk factors for future attacks and death due to asthma in this child e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma ”

    Source location

    Sophie Holman · Prevention of Future Deaths report
    Page 3 · 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

    Failure to initiate referral to a specialist respiratory service

    Wider context from the report

    “In the secondary care there was: a) Failure to recognise and act upon the underlying chronic condition punctuated by a number of severe attacks with life threatening features one of which was a near-fatal attack where Sophie was ‘blue and unresponsive’ with an oxygen saturation of 86% (2.7.2012) b) Failure to recognise the need for and initiate referral of this child to a specialist respiratory service as recommended in the NRAD recommendations c) Failure to take appropriate action when it was known that the family had a home nebuliser d) Failure to implement the recommendations in the NICE Quality Statement 25, and BTS/SIGN guideline to ensure a pre-discharge review of the child’s asthma by an appropriately trained individual e) Failure to effectively communicate changed medication in 2013 of the child to the general practitioner f) Implementation of a hospital policy whereby this child was discharged from secondary care three times because of failure of the parents to bring the child to planned outpatient appointments g) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-evidence based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication ”

    Source location

    Sophie Holman · 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

    Improve access to specialist paediatric care in community settings.

    Verbatim wording from the response

    “We will also be working to improve access to specialist paediatric care in the community, as we know this will have a positive impact. Also through the clinical networks we will continue to share examples of best practice from areas that are”

    Source location

    2019-0035-Response-by-NHS-England
    Page 2 · response
    Published 26 May 2019

    Open published response

  5. Inner West London

    AI-generated summary

    Michael Uriely · 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

    Michael Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.

    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 refer high-risk asthma patients to tertiary respiratory services

    Wider context from the report

    “7) Two further areas of concern presented, inter related but independently significant and critical in this matter: A) Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment. B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by: i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered. ii) The A&E and inpatient service at the local hospital. ”

    Source location

    Michael Uriely · 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

    Failure to complete formal referral to a tertiary respiratory service

    Wider context from the report

    “8) Michael was never formally referred to a tertiary respiratory service. ”

    Source location

    Michael Uriely · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Gateshead and South Tyneside

    AI-generated summary

    Tamara Mills · 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

    Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to refer paediatric asthma patients to tertiary respiratory specialists

    Wider context from the report

    “8. Two further areas of concern presented, inter related but independently significant and critical in this matter : A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment. B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics. i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient. ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care and iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation 9. Tamara was never formally referred to this level of service. ”

    Source location

    Tamara Mills · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Surrey

    AI-generated summary

    Kenneth John WILLIAMS · 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

    Kenneth John Williams was admitted with shortness of breath and was diagnosed with tension pneumothorax, leading to insertion of a chest drain. The report states that the diagnosis was incorrect, the drain ruptured a pulmonary bulla and caused bleeding, and concerns included reviewing previous imaging and medical history and involving the respiratory team before and after chest-drain insertion.

    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 notify the respiratory team about patients with inserted chest drains

    Wider context from the report

    “3. Action is required to ensure the respiratory team is made aware of all patients who have had a chest drain inserted. ”

    Source location

    Kenneth John WILLIAMS · 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

    Failure to seek respiratory consultant opinion before chest drain insertion

    Wider context from the report

    “2. Action is required to ensure respiratory consultants opinion is sought where possible before inserting a chest drain. ”

    Source location

    Kenneth John WILLIAMS · 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

    Cascade instructions requiring respiratory-team involvement and notification for every patient who has had a chest drain inserted.

    Verbatim wording from the response

    “3. Action is required to ensure the respiratory team is made aware of all patients who have had a chest drain inserted.”

    Source location

    2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use a spontaneous-pneumothorax pathway requiring respiratory-team discussion before chest-drain insertion.

    Verbatim wording from the response

    “2. Action is required to ensure a respiratory consultants opinion is sought where possible before inserting a chest drain.”

    Source location

    2015-0135-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 30 March 2015

    Open published response
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Data last updated 7 September 2026