22 Oct 2021 Serena Naomi Roberts · Prevention of Future Deaths report Manchester South
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Concerns raised 6 Poor documentation in GP referrals to secondary care View source Lack of GP referral follow-up systems to identify increased patient risk View source Delays in secondary-care appointments for gynaecological referrals View source Failure of GP referral follow-up systems to escalate referrals when required View source Lack of GP referral follow-up systems to identify referrals that have not taken place View source Failure in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Serena Naomi Roberts · 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
Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Poor documentation in GP referrals to secondary care
Wider context from the report “3. The quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care . Standardisation of GPs referrals in relation to detail and guidance regarding key information for referral would assist with effective triage and identification of high risk patients by secondary care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of GP referral follow-up systems to identify increased patient risk
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Delays in secondary-care appointments for gynaecological referrals
Wider context from the report “1. The inquest heard that there were significant delays in patients being seen in secondary care for gynaecological referrals from GPs . The inquest was told that these delays had now increased . In November 2020 the wait time for an appointment was 1 month for an urgent appointment and 4 months for a routine appointment. The wait times now in Tameside for gynaeocology were 8 months for a routine appointment and 4 months for urgent appointments. The increase in wait times reflected a national picture the inquest was told and reflected a significant backlog and a rising demand across the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure of GP referral follow-up systems to escalate referrals when required
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of GP referral follow-up systems to identify referrals that have not taken place
Wider context from the report “4. There was no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure in General Practice to understand and apply guidance on heavy premenstrual bleeding and expedite specialist referral
Wider context from the report “2. The inquest heard that understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health and that the risks around heavy premenstrual bleeding were not well understood in General Practice and in particular where it was necessary to expedite referral to specialist services .
” Open source report
19 Apr 2018 Adrian Jennings · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Lack of a clear system for joined-up discharge planning between primary and secondary mental health services View source Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance View source Unavailability of identified mental health support services because they were not commissioned View source Failure to use one Trust-wide IT system for information sharing between professionals involved in care View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Adrian Jennings · 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
Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.
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. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system for joined-up discharge planning between primary and secondary mental health services
Wider context from the report “2.there was no clear system for the primary and secondary mental health services of the mental health trust ,Pennine Care, to develop a joined up discharge plan following a stay on the mental health ward ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure of the Lorenzo electronic booking and triage system to capture key information about police conveyance
Wider context from the report “4. Tameside Hospital cannot change their electronic booking in/triage system to allow them to include drop down boxes for key information such as the fact that Police Officers have brought an individual to the Hospital because it is a national IT system. Any trust operating the Lorenzo system will struggle to capture this information at booking in
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Unavailability of identified mental health support services because they were not commissioned
Wider context from the report “3. a need for a type of mental health support service had been identified by the mental health trust Pennine Care but it could not be delivered because the Trust had not been commissioned to deliver the service ; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to NHS Tameside and Glossop Clinical Commissioning Group; that does not assign responsibility.
PFD Monitor interpretation Failure to use one Trust-wide IT system for information sharing between professionals involved in care
Wider context from the report “1. The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust , which impacted on information sharing between professionals involved in his care ;
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations