Recurring concern

Unreliable management of clinical waiting lists

Pin Get email alerts Request correction

First reported 24 May 2016•Latest report 1 May 2025

Definition

What this concern includes

Includes failures in the end-to-end management of clinical waiting lists, including list oversight, prioritisation, progress monitoring, review of prolonged waits, escalation of capacity problems and reassessment or rerouting when the existing pathway is no longer appropriate.

Not included

  • Excludes ordinary appointment or referral delays where no clinical waiting-list management deficiency is identified.
  • Excludes failures to provide treatment or specialist care after a waiting-list process has operated reliably, unless the waiting-list management itself is deficient.
  • Excludes generic staffing, funding or capacity problems that are not directly tied to managing, monitoring, prioritising or escalating clinical waiting lists.
  • Excludes named pathway-specific waiting-list concerns where that pathway provides a narrower supported boundary, unless the assertion also identifies a wider clinical waiting-list management failure.
Reports
8

Distinct published reports

Individual concerns
9

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care3
NHS England3
NHS Greater Manchester Integrated Care Board2
Academy of Medical Royal Colleges1
Birmingham Women'S and Children'S NHS Foundation Trust1
Cornwall Partnership NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
NHS Bury Clinical Commissioning Group1
NHS Cornwall and the Isles of Scilly Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Pennine Care NHS Foundation Trust1
Priory Group1
Royal College of Psychiatrists1
Tameside and Glossop Integrated Care NHS Foundation Trust1
the Robert Jones and Agnes Hunt Orthopaedic Hospital 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. Birmingham and Solihull

    AI-generated summary

    Peter Michael ANZANI · 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

    Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in patient reviews and treatments

    Wider context from the report

    “1. I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (”The Trust”) have been experiencing difficulties with patient waiting lists - due to both an increase in the quantity of patients being treated and staffing shortages - which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months. 2. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a "no growth policy". 3. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming). 4. It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or review, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment. 5. In light of HM Government's decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance. ”

    Source location

    Peter Michael ANZANI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Norfolk

    AI-generated summary

    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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of monitoring and review of patients on routine or urgent waiting lists

    Wider context from the report

    “3. The other concern I have following the evidence heard, is that if someone is on a routine or urgent waiting list, there is no requirement or system in place to monitor their progress. I was advised that those referred under a 2 week wait (which I am now advised has been changed to a 28 day wait) for suspected cancer, will be monitored to ensure that the timescale is met. There is no such requirement for the other waiting lists. This may lead to patients being left waiting for excessive periods, without any requirement for their case to be reviewed to ascertain if it remains suitable for such a lengthy wait, or if a new referral needs to be made on a different pathway. ”

    Source location

    Carla Marie SMITH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. South London

    AI-generated summary

    Sailor (previously known as Sara) COURT · 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

    Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.

    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

    Insufficient capacity to safely assess and re-prioritise urgent CAMHS waiting-list patients

    Wider context from the report

    “(1) The anticipated waiting times before Sailor’s assessment (approximately one year) was unacceptably long. (2) The length of time before treatment could be delivered thereafter (approximately 10 months) was unacceptably long. (3) The Court heard evidence that the waiting times for assessment and treatment have not improved since Sailor’s death, and in fact both have significantly increased. This means that a teenager referred today into the CAMHS could be waiting for around / upwards of two years before they receive treatment. This is an unacceptably long delay. (4) The Court heard evidence that the Trust is attempting to mitigate the problem by way of a proactive “Keeping in Touch” team with the potential to streamline / re-organise the waiting list. However, due to the number of individuals on the waiting list (estimated to be over 1,000) and the number of staff engaged in the Keeping in Touch team (three) and the scale of the task, I was not re-assured that the Keeping in Touch team could realistically and / or safely assess or re-prioritise those on the waiting list in most urgent need of assessment or treatment. (5) The Court heard evidence that the long waiting lists were a result of a lack of resources which has not kept pace with significantly increased (and increasing) demand. ”

    Source location

    Sailor (previously known as Sara) COURT · 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

    Invest in the CYPMH workforce and expand NHS mental health support access for children and young people.

    Verbatim wording from the response

    “Improving mental health support for children and young people is a priority for NHS England. The NHS Long Term Plan (LTP) sets an ambitious commitment that access will increase, with 345,000 more children aged 0-25 accessing support in 2023/24 compared to 2019. This commitment came with significant additional funding, rising to over £900 million in 2023/24. We have made significant progress towards this commitment, with 758,000 children and young people receiving support from the NHS in the 12 months to January 2024. This has been achieved through investment in the CYPMH workforce, which has increased by 46% since the start of the LTP in January 2019, and by 70% since 2016.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 9 August 2024

    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

    Recruit 8,500 additional staff across children’s and adult mental health services.

    Verbatim wording from the response

    “As part of our mission to build an NHS that is fit for the future and that serves the patients that need it, this Government will recruit 8,500 additional staff across children’s and adult mental health services, introduce a specialist mental health professional in every school and roll out Young Futures hubs in every community to intervene earlier with more timely mental health support.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 9 August 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England will address concerns about the keeping in touch team in its response to the report.

    Verbatim wording from the response

    “With regards to your concerns about the “keeping in touch team” at South London and Maudsley NHS Foundation Trust. I have been in touch with Stephen Powis at NHS England to discuss the service. I understand that colleagues at NHS England will address these concerns in more detail in its response to your report.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 9 August 2024

    Open published response
  4. Nottinghamshire

    AI-generated summary

    Kellum Paul Thomas · 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

    Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.

    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 robustly manage the list of children waiting for replacement devices

    Wider context from the report

    “1. Kellum was without a REVEAL device to monitor his heart rate and rhythm for an 18 month period, despite this being an agreed necessary part of his treatment. The evidence from ████████, Consultant Paediatric Cardiologist, was that there was no robust system for clearly identifying when a battery within a REVEAL device, came to the end of its life, nor was there a robust system for managing the list of children waiting for a replacement device. Also that the waiting list for a device change was excessively long (over 12 months for urgent cases, and longer for those less urgent). Also that capacity and resources were very stretched as the Specialist Paediatric Cardiology team dealing with these issues, was small, and covering both East and West Midlands. ”

    Source location

    Kellum Paul Thomas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Manchester North

    AI-generated summary

    Nichola Jane Lomax · 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

    Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

    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

    Failures and delays in maintaining and re-referring patients on the Priory waiting list

    Wider context from the report

    “7) Delay in Re-Referral For GMMH/PRIORY Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS. ”

    Source location

    Nichola Jane Lomax · 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

    Review the Greater Manchester adult eating disorder pathway and revise protocols and collaboration arrangements.

    Verbatim wording from the response

    “The traffic light system in MEED has been endorsed by NHSE/I and is being rolled out across the system in Greater Manchester and nationally now so that, like NEWS 2, we can see significant improvement in risk assessment and triage. There will also be a requirement for all ICSs to have a formally established whole-system MEED group, which we have started for young people and are now starting for adults, with a link across the two to ensure the transitions are also addressed. Greater Manchester have also accelerated the review of the whole adult eating disorders pathway, including revised protocols with our independent sector providers and greater collaboration with the voluntary, community and social enterprise sector providing both prevention and recovery support as well as carer support.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 3 · response
    Published 31 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Broaden the children and young people’s eating disorder working group into an all-age group addressing transitions and consistent referral pathways.

    Verbatim wording from the response

    “In advance of this, GMHSCP MH Programme Team are working with partners to ensure the Children and Young Person’s Eating Disorders working group that is already in place is broadened to become an all-age group. This will address wider transition issues between Children’s and Adult Eating Disorder services - an area of particular concern for this patient group. Actions to ensure connectivity of evidence-based pathways that apply consistent referral criteria will be a key part of the work of this group. It will involve clinicians, commissioners, service providers and service users. This is something that has already been encouraged over the past year in the”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 38 · response
    Published 31 December 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.

    Verbatim wording from the response

    “GMHSCP also acknowledges that the commissioned adult eating disorders service in Bury (like many areas of the country) was insufficient to meet local need. Since then, funding has now also been confirmed between Bury CCG and GMHSCP to implement the GMMH Adult Eating Disorders Business Case.”

    Source location

    2021-0433 - Response regarding Nichola Lomax
    Page 39 · response
    Published 31 December 2021

    Open published response
  6. Manchester South

    AI-generated summary

    Shirley Anne Nightingale · 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

    Shirley Anne Nightingale died at Tameside General Hospital on 20 May 2019 after a catastrophic gastrointestinal bleed. The report identified concerns about the lack of clear systems for prioritising urgent endoscopies, following up requests, and recording or authorising departures from recommended timescales.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a clear clinician escalation and prioritisation system for OGD lists and patient need when OGD capacity is unavailable

    Wider context from the report

    “1. The inquest heard that there was no clear system for escalation /prioritisation by treating clinicians in relation to management of the OGD lists and patient need where the OGD team said there was no capacity; ”

    Source location

    Shirley Anne Nightingale · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Manchester South

    AI-generated summary

    John Paul Derwent · 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

    John Paul Derwent was referred for cognitive behavioural therapy while the waiting time was 12 months against a six-week target. He expressed suicidal ideation, was admitted and later discharged into the community; on 13 November 2017 he was found suspended from a ligature at home. The report raised concerns about insufficient CBT capacity, the substantial waiting list and escalation mechanisms that did not allow early action.

    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 escalation mechanisms to enable early action on excessive CBT waiting lists

    Wider context from the report

    “The Inquest heard that the target time for an appointment for CBT should be 6 weeks. At the time Mr Derwent was referred, the waiting time was 12 months. There was a waiting list review in October 2017 when it was established that 500 people were on the waiting list for CBT. The waiting list time at the date of the Inquest remained 12 months. The Inquest heard that there was insufficient capacity for the number of people referred for CBT which is why the waiting list had become so significant. It was unclear why the list had been allowed to increase to this level. The mechanisms for escalation between the commissioning body and the service provider did not appear to allow for early action to address the issue. ”

    Source location

    John Paul Derwent · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Cornwall and Isles of Scilly

    AI-generated summary

    Simon Jonathon Klemberg · 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

    Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.

    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 ensure procedures prioritise high-risk patients on psychological therapy waiting lists

    Wider context from the report

    “(4) To review procedures for prioritizing high risk patients in waiting lists for psychological therapy. Cornwall Partnership NHS Foundation Trust (CFT) to respond. ”

    Source location

    Simon Jonathon Klemberg · 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 manage waiting lists for individual psychological therapy safely

    Wider context from the report

    “(3) To review the waiting lists for individual psychological therapy. Cornwall Partnership NHS Foundation Trust (CFT) to respond. ”

    Source location

    Simon Jonathon Klemberg · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026