Recurring concern

Unreliable prioritisation of patient reviews

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First reported 27 Nov 2013•Latest report 17 Apr 2025

Definition

What this concern includes

Includes failures to define, communicate or apply priorities for reviewing patients or urgent clinical cases, including decisions made from materially incomplete clinical information.

Not included

  • Emergency-department triage or ambulance call categorisation governed by a separately named system
  • Prioritisation of treatment, surgery or investigations after the required patient review has occurred
  • Generic staffing or workload concerns without a directly deficient patient-review prioritisation process
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
12

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.

Cwm Taf Morgannwg University Local Health Board1
Essex County Council1
Heatherwood and Wexham Park Hospitals NHS Foundation Trust1
Mersey Care NHS Foundation Trust1
Sheffield Health Partnership University 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. Essex

    AI-generated summary

    Linda Sitch · 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

    Linda took her own life on 11 November 2023 after prolonged strain associated with caring for her husband, who had significant physical and mental health problems. Adult Social Care did not substantively respond to safeguarding and carer assessment referrals or the family’s escalating concerns before her death. The report raises concerns about inadequate oversight and the risk that urgent referrals could be inappropriately downgraded or insufficiently reviewed, potentially contributing to future 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

    Failure to ensure thorough, professional and adequately documented review of urgent referral grading

    Wider context from the report

    “d. In contrast to this view, I remain concerned that ASC continues to lack a robust system to ensure sufficiently rigorous oversight, including active auditing, capable of identifying the kind of sub-optimal managerial level performance as has been brought to the fore in this case. A change in personnel and moves towards “embedding best practice” do not, in my opinion, sufficiently address this systemic lacuna given that the effectiveness of such changes will still rely very substantially upon the performance of any Team Manager and/or a Deputy Team Manager. There appears to me to be a continuing lack of robust Service level oversight of those managers themselves, (including the appropriateness of their decision making), absent which any sub-optimal performance by said managers may well not be identified. e. Absent a sufficiently robust system for providing oversight and identifying and significantly mitigating (if not entirely removing) such individual human error, alongside, for example, the inclusion of simple auditable check lists of matters to be accessed, reviewed and documented whenever a referral is received, then there is a continuing risk of urgent future referrals being inappropriately graded as Priority 2 (and/or being downgraded from Priority 1) without the requisite thorough and professional review, adequately documented, being undertaken. This gives rise to a concomitant risk of future deaths. ”

    Source location

    Linda Sitch · 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

    Introduce carers practice guidance and core practice guidance covering assessments, reviews, support planning and safeguarding.

    Verbatim wording from the response

    “• New Carers practice guidance for Adult Social Care operational workers to support better and more timely outcomes for carers.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 28 April 2025

    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 risk-priority matrices for carers’ assessments, reviews and safeguarding referrals.

    Verbatim wording from the response

    “• A new Risk Priority Matrix for carers assessments and reviews was implemented in 2023, which was being embedded throughout the year.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 28 April 2025

    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

    Conduct a scheduled audit of referral progression through allocation and consider issuing further guidance on priority decisions and allocation timescales.

    Verbatim wording from the response

    “Adult Social Care have scheduled an audit cycle within the next three months, specifically focused on how referrals are progressed when an initial referral is received, through to point of allocation. Following analysis and outcomes of this, we will consider issuing further practice guidance to confirm expectations about making good, defensible decisions around priority levels, including expected timescale for the allocation of work.”

    Source location

    Response from Essex County Council
    Page 3 · response
    Published 28 April 2025

    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

    Refresh the Quality Assurance Framework and conduct eight annual audit cycles covering assessments, reviews, mental capacity and safeguarding, with findings reported to the Practice Governance Board.

    Verbatim wording from the response

    “Alongside the Quality Control measures in place, Adult Social Care refreshed its Quality Assurance Framework in 2024 and there are now eight audit cycles in place throughout every year. These focus on care act assessments/reviews, carers assessments, mental capacity assessments and safeguarding. Audits are analysed and reports are presented to the Practice Governance Board.”

    Source location

    Response from Essex County Council
    Page 5 · response
    Published 28 April 2025

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Bryan Andrews and Mary Andrews · 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

    Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important 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 identify urgency in referrals involving paranoia, delusions and suicidal ideation

    Wider context from the report

    “There was a lack of communication between services about the relationship between the diagnosis of epilepsy and the psychotic symptoms experienced by the person responsible for the deaths. This led to significant time lapses in treatment and rejection of referrals, most notably: i. On 18 November 2020 an urgent referral was made to the Single Point of Access Team by his General Practitioner, concerned about his prolonged suicidal ideation. He was referred back to his General Practitioner by the Single Point of Access Team with a request that the General Practitioner refer him to access the Improving Access to Psychological Therapies Service. ii. On 20 November 2020 his General Practitioner referred him to the Single Point of Access Team again, requesting they liaise with the Improving Access to Psychological Therapies Service as per Trust guidelines. iii. Correspondence between the Improving Access to Psychological Therapies Service and the Single Point of Access Team revealed that whilst the Improving Access to Psychological Therapies Service offered work on living with chronic conditions, they did not have a programme specific to epilepsy. A referral to the Neurology Therapy Service was made and it was decided a request to the General Practitioner for the mental health nurse in the surgery to offer an assessment was appropriate. The surgery were not informed of this. iv. On 16 December 2020 the Single Point of Access Team received a referral from a consultant neurologist requesting a medication review as his anxiety levels were affecting his epilepsy treatment. It was felt at that as the General Practitioner was reviewing his medication, a review wasn’t required. This was not communicated to the consultant neurologist. v. On 29 April 2022 he called the Single Point of Access Team saying he was having a serious psychotic episode and thought he was going to kill someone. The call was treated as a crisis call during which he decided to attend the emergency department. Once there he was assessed by the Liaison Psychiatry Team. He was referred to the Home Treatment Team, but his consultant neurologist was not informed. vi. On 3 May 2022 a trial of anti-psychotic medication was discussed at a medical review. The required consultant review of whether to prescribe anti-psychotic medication with his epilepsy medication was not carried out. vii. On 4 May 2022 a referral to the Early Intervention Service was rejected as not meeting the criteria for first episode psychosis, despite clear evidence of psychosis in the assessment by the Liaison Psychiatry Team on 29 April 2022 and in subsequent contacts with the Home Treatment Team. viii. On 5 May 2022 a first referral was made to the Emotional Wellbeing Service via email asking for their input into his care. The email was sent to an address not manned daily. When a response was provided it was unclear whether a new treatment episode had been opened. ix. On 09 May 2022 he was discharged from the Home Treatment Team. The discharge was reliant on Emotional Wellbeing Service intervention and a follow up from his General Practitioner. A discharge summary was not sent to his General Practitioner. x. On 4 October 2022 a referral was sent to the Single Point of Access Team by his General Practitioner that he was presenting as paranoid and delusional with suicidal ideation. A screen for urgency found this was a routine referral. The referral was triaged on 22 November 2022 when he was invited to contact the Single Point of Access Team for a further discussion. ”

    Source location

    Bryan Andrews and Mary Andrews · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    No further action is proposed for Single Point of Access referrals because that service no longer operates and referrals now enter individual services.

    Verbatim wording from the response

    “The Single Point of Access Service within SHSC is no longer in operation, following a transformation programme of our Urgent and Crisis Services. We have, therefore, not set out any actions in this response relating to how this service deals with referrals, given that referrals now go into each individual service. We are committed to taking the following actions:”

    Source location

    Response from Sheffield Health and Social Care
    Page 1 · response
    Published 8 October 2024

    Open published response

  3. South Wales Central

    AI-generated summary

    Sara GRINNELL · 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

    Sara Grinnell experienced excessive vaginal bleeding and menorrhagia, with repeated referrals to gynaecology before being diagnosed with endometrial cancer in June 2021. A planned hysterectomy was postponed, her treatment options became palliative, and she died on 11 April 2022. The principal concerns were delays exceeding 22 weeks in contacting her after an urgent referral, reliance on written correspondence without further contact methods, insufficient regard to earlier referrals, and a 24-month delay between urgent referral and diagnosis.

    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 account for earlier referrals and existing delays when reassessing urgency of gynaecology contact

    Wider context from the report

    “(1) Following an ultrasound scan performed in June 2019, and urgent referral to the Gynaecology Department, there was extensive delay in excess of 22 weeks in attempting to contact the patient with an urgent appointment. (2) The means of contacting the patient for an Urgent Gynaecology appointment was via written correspondence without further consideration of other means via telephone, email, or via G.P. (3) When the G.P re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact. (3) As a consequence, this resulted a significant delay of 24 months between the urgent referral to Gynaecology Department and eventual diagnosis. ”

    Source location

    Sara GRINNELL · 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

    Update triage procedures and implement electronic triage to support consistent 24–48-hour allocation.

    Verbatim wording from the response

    “Improve triaging process; update the triage proforma, agreement of daily triage allocation; implementation of electronic triage (WPRS)”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 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

    Hold CTM gynaecology cancer oversight meetings to review performance, patients, escalations and waiting times.

    Verbatim wording from the response

    “Establish CTM Gynae cancer oversight meetings (implemented from 11th May)”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 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

    Strengthen harm reviews through robust clinical MDT review of patients waiting more than 104 days.

    Verbatim wording from the response

    “Improve harm review process”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 5 · response
    Published 17 September 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

    The Health Board disputes that the re-referral met urgent suspected cancer criteria, stating the case was reviewed by the GP and a specialist.

    Verbatim wording from the response

    “3) When the G.P. re-referred the patient to the Gynaecology Department due to ongoing and worsening symptoms, there was a lack of regard to earlier referrals and the extensive delay that had already occurred and a missed opportunity to escalate the urgency of contact.”

    Source location

    Response from Cwn Taf Morgannwg University Health Board
    Page 3 · response
    Published 17 September 2024

    Open published response

  4. Manchester West

    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 to prioritise referrals within urgency categories

    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

    Require the senior nurse practitioner on duty to clinically review unprioritised referrals and assign a priority within 30 minutes.

    Verbatim wording from the response

    “I. It is the referrer and not an administrator who categorises referrals. A system is in place whereby administration staff place referrals in an appropriate tray based on the referral priority provided by the referrer, who is usually a general practitioner. Where no priority has been identified by the referrer this is now brought to the immediate attention of the senior nurse practitioner on duty who will review the referral and assign the appropriate clinical priority within a maximum of 30 minutes of receipt.”

    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

    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

    Deliver lessons-learned training, update team guidance and systems, and cascade the learning across the other assessment teams.

    Verbatim wording from the response

    “VIII. Training in the form of ‘lessons learned’ took place on 22 January 2014 and included an update of guidance and systems currently in place within the team. This has been cascaded across the other assessment teams and will be shared at the Quality and Governance Meeting in February 2014.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 3 · response
    Published 27 December 2013

    Open published response

  5. Berkshire

    AI-generated summary

    Edna Elsie Mary Eden · 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

    Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

    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 base patient-review prioritisation on sufficiently detailed clinical information

    Wider context from the report

    “(4) Clinicians were taking decisions over priority of seeing patients based only on a very vague description of Mrs Eden’s condition. Information at handovers appeared very limited. ”

    Source location

    Edna Elsie Mary Eden · 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

    Strengthen use of the SBAR communication tool when notifying doctors about patients requiring review.

    Verbatim wording from the response

    “In addition TPP 231 has strengthened the use of Situation Background Assessment Recommendation (SBAR) tool. This is a communication tool used when notifying Doctors over the phone or in person of a patient for review. The tool ensures important information is conveyed in order to allow the Doctor to paint a picture of the patient’s condition and prioritise review as necessary.”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response
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Data last updated 7 September 2026