Recurring concern

Unreliable triage of GP referrals across referral routes

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First reported 10 May 2023•Latest report 30 Mar 2026

Definition

What this concern includes

Includes failures in the process for receiving, recognising, weighting, recording, routing or prioritising GP referrals, including referrals arriving through non-standard routes or through direct presentation to an emergency department, where the route can affect triage and clinical assessment.

Not included

Excludes general emergency-department triage failures where no GP referral or referral-route issue is identified.
Excludes generic referral delays, missing referral information or GP communication failures where GP-referral triage across routes is not the shared unsafe condition.
Excludes clinical assessment or treatment failures after a GP referral has been correctly triaged and routed.
Excludes GP appointment triage and specialist referral pathways unless the assertion specifically concerns triage of GP referrals across referral routes.

Reports: 2
Individual concerns: 2
Date range: 2023–2026
Stated actions: 8

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.

George Eliot Hospital NHS Trust1

NHS England1

Royal College of General Practitioners1

Sheffield Children'S 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.

30 Mar2026
Warwickshire
Concerns raised1
1. Lack of GP awareness of referral-route implications for local hospital triage and assessment
This report raised 7 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 6
1. Action
  Implement and disseminate an EMIS and laminated referral protocol covering paediatric pathways, hospital selection, advance contact, documentation and clinically appropriate ambulance transfer.
  Stated by Old Mill SurgeryStated completed
2. Action
  Issue a joint statement calling for improved primary-care access to specialist advice and expanded same-day emergency care options.
  Stated by Royal College of General PractitionersStated completed
3. Action
  Communicate referral-route risks and Prevention of Future Deaths learning to members through a generic educational webinar.
  Stated by Royal College of General PractitionersStated planned
1. Action
  Review the Directory of Services with system partners to improve awareness of local adult and paediatric services.
  Stated by George Eliot Hospital NHS TrustStated in progress
2. Action
  Evaluate an electronic interface with the Directory of Services for General Practice.
  Stated by George Eliot Hospital NHS TrustStated planned
3. Action
  Develop and disseminate coordinated communications describing GEH and SWFT services to referral partners and the public.
  Stated by George Eliot Hospital NHS TrustStated in progress
AI-generated summary

Ethan Michael Hanson · 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

Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital 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
Lack of GP awareness of referral-route implications for local hospital triage and assessment
Wider context from the report
“Critical GP information not carried forward into the hospital assessment The GP identified the possibility of appendicitis or another serious underlying cause and recorded abnormal observations. The absence of an ambulance conveyance or written referral letter meant this information was not transferred to the hospital. As a result, Ethan entered a different clinical pathway, and the assessing clinician was unaware of the GP’s concerns. There is a wider risk that GPs may not be aware of the implications of referral route on triage and assessment in local hospitals, and that critical deterioration indicators can be lost at the point of transfer. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · 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
Implement and disseminate an EMIS and laminated referral protocol covering paediatric pathways, hospital selection, advance contact, documentation and clinically appropriate ambulance transfer.

Verbatim wording from the response
“Following this event, we have implemented a new protocol within our EMIS clinical system and also laminated the protocol and displayed in all clinical rooms. This protocol prompts all clinicians, at the point of referral, to:”

Source location
Response from Old Mill Surgery GP
Page 1 · response
Published 25 June 2026
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
Issue a joint statement calling for improved primary-care access to specialist advice and expanded same-day emergency care options.

Verbatim wording from the response
“Work on the interface between primary and secondary care included a joint statement between RCGP, RCP, SAM and Royal College of Emergency Medicine calling for secondary care to improve primary care access to specialist advice via dedicated telephone lines and urgent expansion of SDEC options for primary care and 111 services. GP awareness of impact of referral letter and ambulance conveyance on clinical pathways within Emergency care, opportunities to communicate this to GPs.”

Source location
Response from Royal College of General Practitioners
Page 2 · response
Published 25 June 2026
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
Communicate referral-route risks and Prevention of Future Deaths learning to members through a generic educational webinar.

Verbatim wording from the response
“I intend to communicate this issue to members alongside learning from Prevention of Future Death Reports in a Webinar format for dissemination of learning, ensuring principles being highlighted are generic and not attributable to individual cases, nor impacting ongoing proceedings that follow each coronial review.”

Source location
Response from Royal College of General Practitioners
Page 2 · response
Published 25 June 2026
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 the Directory of Services with system partners to improve awareness of local adult and paediatric services.

Verbatim wording from the response
“The Trust is undertaking a review of the Directory of Services with system partners to ensure an awareness of services delivered across all local hospitals for both adults and paediatrics. It is envisaged that this will be completed by the end of July 2026.”

Source location
Response from George Eliot Hospital NHS Trust
Page 6 · response
Published 25 June 2026
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
Evaluate an electronic interface with the Directory of Services for General Practice.

Verbatim wording from the response
“• The Trust will undertake an evaluation of an electronic interface with the Directory of Services for General Practice, with the aim of ensuring that the most current and accurate information is consistently accessible to all GPs. This work is scheduled for completion by the end of July 2026.”

Source location
Response from George Eliot Hospital NHS Trust
Page 6 · response
Published 25 June 2026
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
Develop and disseminate coordinated communications describing GEH and SWFT services to referral partners and the public.

Verbatim wording from the response
“• The Trust is developing a coordinated communications programme to clearly articulate the range of services provided across GEH and SWFT. This will be”

Source location
Response from George Eliot Hospital NHS Trust
Page 6 · response
Published 25 June 2026
Open published response
10 May2023
South Yorkshire (Western)
Concerns raised1
1. Insufficient weight given to GP referrals arriving outside the identified referral route
This report raised 5 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 2
1. Action
  Send primary-care communications reminding providers to use the correct referral pathway and provide parents with the explanatory leaflet.
  Stated by Sheffield Children'S NHS Foundation TrustStated completed
2. Action
  Work with primary-care colleagues towards a more permanent solution for the referral pathway.
  Stated by Sheffield Children'S NHS Foundation TrustStated in progress
AI-generated summary

James Philliskirk · 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

James Philliskirk was assessed twice in A&E after becoming unwell following a recent chickenpox infection and was sent home on both occasions. He developed sepsis and died at home on 13 May 2022. Concerns included failures to escalate to senior staff, unclear guidance on chickenpox reinfection and secondary complications, confirmation bias, inadequate assessment of skin lesions, and insufficient weight given to GP referral outside the usual route.

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 weight given to GP referrals arriving outside the identified referral route
Wider context from the report
“6. Insufficient weight on GP referral when not through the identified route of referral (ie presentation straight to A&E which amounts to 25% of referrals). I heard evidence that an IT system is in development to resolve this however engagement of NHS Digital and the Commissioners is required to progress. For the avoidance of doubt, had the GP referral been processed in the usual way James would have gone through to the medical unit and the result would have been senior oversight and a strong likelihood that James would have received IV antibiotics and survived. ”
Source location
James Philliskirk · 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
Send primary-care communications reminding providers to use the correct referral pathway and provide parents with the explanatory leaflet.

Verbatim wording from the response
“As confirmed in evidence at the inquest, a reminder has been sent via the Integrated Care Board communications team to primary care, reminding them of the current referral system, so that the correct referral pathway is used, including a reminder to provide a copy of a new leaflet to parents explaining the system in place and the need to attend AAU (The Acute Assessment Unit).”

Source location
Response from Sheffield Children's NHS Foundation Trust 2
Page 3 · response
Published 18 October 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
Work with primary-care colleagues towards a more permanent solution for the referral pathway.

Verbatim wording from the response
“Our clinical management team will be working with our primary care colleagues towards a more permanent solution for the referral aspect of the patient pathway. At this time, we are unable to confirm whether this will require a digital solution such as an electronic referral system but have oversight from our digital colleagues to ensure that if such a solution is required it can be practically implemented.”

Source location
Response from Sheffield Children's NHS Foundation Trust 2
Page 3 · response
Published 18 October 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of GP awareness of referral-route implications for local hospital triage and assessment

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.6

Concerns raised1

Insufficient weight given to GP referrals arriving outside the identified referral route

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

Actions described in response 6

Actions described in response 2