Recurring concern

Unreliable Gateway referral and assessment process

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First reported 27 Dec 2013•Latest report 4 Oct 2019

Definition

What this concern includes

Includes failures in the named Gateway Team process from receipt and urgency allocation of referrals through prioritisation, access to relevant clinical information, contact and reassessment, handover, staffing or resource coordination, and completion of the Gateway assessment and resulting plan.

Not included

Excludes generic referral, staffing, communication or record-access deficiencies that are not specifically part of the Gateway referral and assessment process.
Excludes failures in unrelated mental-health, social-care or specialist referral pathways unless the assertion explicitly concerns the Gateway Team process.
Excludes clinical treatment or follow-up after a Gateway assessment has been reliably completed and communicated.
Excludes the existing narrower concern concerning referral urgency categorisation and prioritisation when the assertion is limited to that component and does not support the wider Gateway process.

Reports: 2
Individual concerns: 3
Date range: 2013–2019
Stated actions: 7

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Mersey Care NHS Foundation Trust1

Swansea Bay University Local Health Board1

Concerns and responses across reports

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

4 Oct2019
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to provide gateway assessors with full access to relevant review and concern notes
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.
Actions described in response 2
1. Action
  Request all PARIS electronic records when obtaining mental health notes for Coroner disclosure.
  Stated by Swansea Bay University Local Health BoardStated completed
2. Action
  Identify all possible mental health patient-record locations and develop a checklist for auditing record completeness before disclosure to the Coroner.
  Stated by Swansea Bay University Local Health BoardStated planned
AI-generated summary

Jane Diane Livingston · 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

Jane Diane Livingston was receiving treatment for anxiety and depression and died by suicide after being found hanging in a multi-storey car park on Trawler Road, Swansea. The report identified concern that gateway assessors did not have access to her earlier review and stated concerns, potentially leading to an assessment and treatment plan based on incomplete information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide gateway assessors with full access to relevant review and concern notes
Wider context from the report
“During the course of the inquest it was apparent that the deceased’s wishes for hospital treatment and the reasons behind the same were not available to the gateway assessors on the 14th of December 2018. In this case the deceased underwent further assessments therefore the effects of this situation were reduced. I am concerned however that in other cases this could result in situations where a patient’s own concerns are not addressed or taken into consideration when conducting an assessment that could lead to an assessment based on incomplete information and result in another patient taking their own life. 1. The gateway assessors did not have full access to the notes relating to the review and subsequent concerns that triggered the gateway assessment. This may result in the assessors not obtaining the full picture when assessing a patient and making a treatment plan based on incomplete information. ”
Source location
Jane Diane Livingston · 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
Request all PARIS electronic records when obtaining mental health notes for Coroner disclosure.

Verbatim wording from the response
“• When requesting a copy of mental health notes, a specific request is now also made for all PARIS electronic records by the Corporate Legal Team.”

Source location
2019-0359-Response-from-Swansea-Bay-University-Health-Board_Published.pdf
Page 3 · response
Published 22 November 2019
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
Identify all possible mental health patient-record locations and develop a checklist for auditing record completeness before disclosure to the Coroner.

Verbatim wording from the response
“• The Mental Health Quality and Safety team will identify all the possible locations of patient records across mental health Services, this information will be used to develop a checklist, which can be used to audit the completeness of records prior those records being disclosed to HMC Coroner. This will be completed by 21st December 2019.”

Source location
2019-0359-Response-from-Swansea-Bay-University-Health-Board_Published.pdf
Page 3 · response
Published 22 November 2019
Open published response
27 Dec2013
Manchester West
Concerns raised2
1. Failure of handover and review systems to manage failed-contact referrals
2. Failure of team management to coordinate and allocate referral-handling resources
This report raised 6 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.
Actions described in response 5
1. Action
  Keep referrals pending contact in the referral tray while making at least three telephone calls within 24 hours and arrange face-to-face visits for urgent cases.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated completed
2. Action
  Review uncontacted routine referrals in the next-day multidisciplinary meeting and record decisions and formal shift handovers in the electronic information system.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated completed
3. Action
  Introduce daily recorded morning meetings to identify referrals and delegate shift actions and responsibilities.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated completed
1. Action
  Establish full assessment-team staffing, recruit all vacancies and provide rota coverage across the 24-hour period.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated completed
2. Action
  Undertake an Acute Care Pathway review covering staffing, skill mix and pathway effectiveness across teams.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progress
AI-generated summary

Howard Simon Sankey · 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

Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff 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 of handover and review systems to manage failed-contact referrals
Wider context from the report
“(1) During the Inquest evidence was heard that :- i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt. ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user. iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team. iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day. Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day. v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013. vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral. 2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to: i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral. iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed. iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners. v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed. vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day. vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period. viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods. ”
Source location
Howard Simon Sankey · 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 of team management to coordinate and allocate referral-handling resources
Wider context from the report
“(1) During the Inquest evidence was heard that :- i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt. ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user. iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team. iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day. Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day. v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013. vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral. 2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to: i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral. iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed. iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners. v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed. vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day. vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period. viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods. ”
Source location
Howard Simon Sankey · 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
Keep referrals pending contact in the referral tray while making at least three telephone calls within 24 hours and arrange face-to-face visits for urgent cases.

Verbatim wording from the response
“V. There is a system in place where the referral/case notes will stay in the referral tray until at least three telephone calls have been made to the service user within a maximum of a 24 hour time frame. The purpose of the telephone calls to the service user is to enable further information gathering to assist with the prioritisation of the referral and to arrange a mutually agreed appointment date and time. A further system is in place which indicates that after this time, a face to face unplanned visit will be arranged for urgent referrals which will take place at the address provided by the referrer.”

Source location
2013-0361-Response-by-5-Boroughs-Partnership
Page 2 · response
Published 27 December 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review uncontacted routine referrals in the next-day multidisciplinary meeting and record decisions and formal shift handovers in the electronic information system.

Verbatim wording from the response
“In the case of referrals considered to be of a routine nature, they are discussed the next day in the morning meeting and a decision taken as to whether the cases need to be reprioritised. A multi-disciplinary team decision is taken on the next action required, which can include an increase in referral priority or further discussions with the referrer on the appropriate course of action.”

Source location
2013-0361-Response-by-5-Boroughs-Partnership
Page 2 · response
Published 27 December 2013
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce daily recorded morning meetings to identify referrals and delegate shift actions and responsibilities.

Verbatim wording from the response
“I can assure you that as a Trust we take the management of referrals very seriously and I can confirm that the management of referrals within the Assessment Team has been reviewed. Whilst it was never the role of the administrative staff to assign a referral priority, the assessment team does have a robust system in place to ensure all referrals accepted by the team, are reviewed by a senior clinical member of staff without any undue delay. A system has been introduced whereby the team have a daily recorded morning meeting in which referrals are identified and actions or responsibilities for the shift are delegated.”

Source location
2013-0361-Response-by-5-Boroughs-Partnership
Page 3 · response
Published 27 December 2013
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
Establish full assessment-team staffing, recruit all vacancies and provide rota coverage across the 24-hour period.

Verbatim wording from the response
“IV. The work of the assessment team can be unpredictable due to the unplanned nature of referrals. I can confirm that whilst at the time of the incident, the team had gaps in staffing due to sickness and vacancies; the team is now fully established. Sickness continues to be proactively managed at a local level and monitored across the entire business stream in line with Trust policy. Staff work to a rota that ensures maximum coverage across the 24 hour period.”

Source location
2013-0361-Response-by-5-Boroughs-Partnership
Page 2 · response
Published 27 December 2013
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
Undertake an Acute Care Pathway review covering staffing, skill mix and pathway effectiveness across teams.

Verbatim wording from the response
“VII. The Trust are currently undertaking a review of the entire Acute Care Pathway (ACP) which includes a review of staffing levels and skill mix across all teams and the effectiveness of pathways between services. This is due to be reported at the end of February 2014. The team manager receives regular management supervision where the concerns you have raised have been discussed and action taken.”

Source location
2013-0361-Response-by-5-Boroughs-Partnership
Page 3 · response
Published 27 December 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide gateway assessors with full access to relevant review and concern notes

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.2

Concerns raised2

Failure of handover and review systems to manage failed-contact referrals

Failure of team management to coordinate and allocate referral-handling resources

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

Actions described in response 2

Actions described in response 5