Recurring concern

Unreliable transfer of triage information for urgent clinical appointments

First to latest report 24 Aug 2016 — 6 Mar 2018

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
1

What this concern includes

Includes failures in the bounded triage-to-urgent-appointment information process, including transfer of triage notes, communication of urgency between triage staff, availability of triage information to the appointment clinician, and related controls needed to preserve clinically important triage information across staff handoffs.

What is not included
  • Excludes generic referral triage failures where the concern is not transfer of triage information for an urgent clinical appointment.
  • Excludes emergency-department, ambulance or telephone-triage systems unless the assertion specifically concerns the same urgent clinical appointment information-transfer process.
  • Excludes appointment scheduling or clinical assessment failures occurring after relevant triage information and urgency have been reliably transferred.
  • Excludes generic communication, documentation or staffing deficiencies unless they directly impair transfer of triage information for an urgent clinical appointment.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Gwent

    AI-generated summary

    ELLIE MAY CLARK · 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

    Ellie May Clark was a child with severe asthma who became seriously unwell after attending her GP surgery and was later found to have died from bronchial asthma. The report identified concerns about care planning, triage delays and systems, her being turned away from an emergency appointment without clinical assessment or safeguarding advice, the recording of her severe asthma, and staff support when challenging decisions.

    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 continuity and availability of triage information for emergency appointment clinicians

    Wider context from the report

    “(4) The lack of an effective and robust triage system. The receptionist who spoke with ████████ on the telephone and the doctor who triaged Ellie were different to the receptionist ████████ spoke with at the surgery and the doctor with whom the emergency appointment was booked. Furthermore, the triage notes were not made available to the doctor in readiness for the emergency appointment. ”

    Source location

    ELLIE MAY CLARK · 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

    Direct management of service delivery and oversight of independent primary care contractor staff falls outside the Health Board’s functions.

    Verbatim wording from the response

    “It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.”

    Source location

    2018-0066-Response-by-University-Health-Board
    Page 1 · response
    Published 16 June 2018

    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

    Independent primary care contractors are responsible for safe service delivery, professional standards, regulatory compliance and patient accessibility.

    Verbatim wording from the response

    “It may be helpful to clarify that the Health Board does not directly manage the delivery of services or the oversight of staff employed within independent primary care contractors. Independent contractors are directly responsible for ensuring that the delivery of services is safe and also for ensuring that services conform to the expected professional standards and regulations and are appropriately accessible to patients. Nonetheless, there is a requirement for practices to provide assurance to the Health Board in respect of the adequacy of services provided. The Health Board has established processes to monitor the compliance of practices with contractual requirements and to intervene where it has concerns, contractually or professionally.”

    Source location

    2018-0066-Response-by-University-Health-Board
    Page 1 · response
    Published 16 June 2018

    Open published response

  2. Cheshire

    AI-generated summary

    Joyce Mary Ravenhill · 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

    Joyce Mary Ravenhill became ill with abdominal pain and vomiting on Christmas Day 2015, was not given an earlier out-of-hours doctor appointment after two triage assessments, and was later found to have an incarcerated femoral hernia causing intestinal obstruction. She underwent surgery but died on 2 January 2016; the principal concern was that there was no facility or operational policy to communicate the urgency of the first triage assessment to the second triage nurse.

    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 an operational policy for communicating urgent doctor’s appointment needs between triage nurses

    Wider context from the report

    “Although a summary of the first triage assessment on 26th December 2015 was available to the second triage nurse, there was no facility / operational policy whereby the simple fact that the deceased needed an urgent doctor’s appointment could be effectively communicated by the first triage nurse to the second, all information and communication being automatically electronically generated. ”

    Source location

    Joyce Mary Ravenhill · 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

    Apply a procedure requiring staff to manually record attempted but unavailable appointment bookings.

    Verbatim wording from the response

    “At NWAS a procedure has been applied for all staff to manually note where an appointment booking has been attempted, but found not to be possible.”

    Source location

    2016-0303-Response-by-North-West-Ambulance-Service-NHS-Trust
    Page 3 · response
    Published 24 August 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026