Concerns raised 6 Failure of screening committee oversight to ensure referrals are received and actioned View source Failure to direct screening referrals to the vascular screening team View source Uncertainty within general practice about the screening programme and referral criteria View source Absence of a system to direct screening requests to the correct department View source Failure by radiology to appropriately process screening referrals View source Failure to take further action when screening requests are refused View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Michael John Halfpenny · 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
Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.
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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of screening committee oversight to ensure referrals are received and actioned
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned .
” 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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to direct screening referrals to the vascular screening team
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Uncertainty within general practice about the screening programme and referral criteria
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Absence of a system to direct screening requests to the correct department
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure by radiology to appropriately process screening referrals
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” 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 The Glenfield Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action when screening requests are refused
Wider context from the report “Regarding the General Practice involvement
- The referral should have been made directly to the vascular screening team but was made to the radiology department
- No further action was taken when the screening request was refused
- The court heard that screening has been in place in Leicester since the 1990’s and nationally since 2013, and that the family saw posters advertising the service on display at Leicester Royal Infirmary but not at the GP surgery.
- The GP practice were uncertain of the existing screening programme and on what criteria to refer patients
Regarding the University Hospitals of Leicester NHS Trust
- The referral request was marked by the radiology department that screening was “not offered” and the request was refused
- The vascular team were unaware of the patient and the request and no system was in place to ensure any screening request was directed to the correct department
- The screening committee group set up by UHL were unaware of this matter and therefore had taken no action to ensure referrals were appropriately received and actioned.
” Open source report
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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 Include AAA referral and screening learning in the Leicestershire LMC newsletter.
Verbatim wording from the response “Obviously, this tragic case has caused all of us to read up about the screening and ask searching questions as a result of which, I have personally completed an SEA. My partner, ████████, who is Chair of the Leicester Medical Committee has included an article in the LMCs newsletter to disseminate learning to the entire GP community. He has also written a formal report for the Coroner detailing his involvement and including a copy of my letter to yourselves as well as my SEA report.” Source location Response from Glenfield Surgery
Open published response
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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 Complete and share a significant event analysis on AAA referral and screening learning.
Verbatim wording from the response “NC originally brought up this case for discussion in our practice meeting. Obviously following which, I was then able to investigate my involvement in the case. I have reflected on how aortic aneurysm should be investigated and have written with my own concerns about the Radiology Departments dealing of my referral in the hope they will reflect upon this and reach their own lessons on this tragic case. I have discussed the case with my partners and have provided this SEA to be sent with my colleagues report to the Coroner. I will ensure a copy of this and my letter to ████████.” Source location Response from Glenfield Surgery
Open published response
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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 Disseminate the significant event analysis to the South Leicestershire locality GP group.
Verbatim wording from the response “In order to disseminate learning to the wider GP community, I have taken the liberty of including a significant event analysis to our locality group which includes a number of practices that work within the South Leicestershire area.” Source location Response from Glenfield Surgery
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations