Recipient

Townhead Surgery

First report 25 Apr 2025•Latest report 25 Apr 2025

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Townhead Surgery linked to the concerns in each report. Select any concern, action or position to view the source wording.

25 Apr2025
North Yorkshire and York
Concerns raised1
1. Failure of completed referral documents to automatically generate alerts for colleagues to action referrals
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Review the referral process through a significant event meeting to identify failures and prevent recurrence.
  Stated completed
2. Action
  Request removal of the GP Assist option that allows referral forms to be sent without a secretarial alert.
  Stated completed
3. Action
  Escalate the referral safety concern to the Integrated Care Board and raise awareness among other practices.
  Stated in progress
1. Action
  Operate a fortnightly internal report to identify unsent Rapid Access Chest Pain referrals.
  Stated completed
Respondent positions 1
1. Position
  Responsibility for the referral form and process lies with Airedale Hospital’s cardiology and IT departments, not the GP surgery.
  Redirects responsibility
AI-generated summary

Richard James MOSS · 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

Richard James Moss attended his general practitioner with intermittent chest discomfort on 15 March 2024 and was later found deceased on 29 May 2024; the recorded cause of death was myocardial infarction due to coronary artery thrombosis. His intended referral to the Rapid Access Chest Pain Clinic had not been actioned, and the practice referral system only alerted colleagues when a practitioner manually selected the alert option.

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 Townhead Surgery; that does not assign responsibility.
PFD Monitor interpretation
Failure of completed referral documents to automatically generate alerts for colleagues to action referrals
Wider context from the report
“When a referral document is completed by a medical practitioner at this practice, an alert to colleagues to action the referral will only be sent if the practitioner manually selects the option to do so rather than every referral document completion automatically generating an alert. ”
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
Review the referral process through a significant event meeting to identify failures and prevent recurrence.

Verbatim wording from the response
“We held a significant event meeting 23.07.24 for the GPs and Practice Manager. The purpose of the meeting was to determine whether anything had gone wrong with our referral process, and if so, could we prevent a recurrence. We determined that the Rapid Access Chest Pain referral form sits within an IT software system called “GP Assist.” GP Assist is used by all local GP surgeries to generate referrals to secondary care. In this case “GP Assist” gives the referring GP the option to either 1) Open the document and send a task (to secretaries) at the same time, or 2) Open the document only (no task generated unless done so manually). Dr Kerry used option 2) and once the referral form had been completed there was no automatic reminder to alert the secretarial team.”

Source location
Response from Townhead Surgery
Page 1 · response
Published 19 May 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
Request removal of the GP Assist option that allows referral forms to be sent without a secretarial alert.

Verbatim wording from the response
“Following the significant event meeting we approached GP Assist to ask that they remove option 2) from the clinical system. We felt this would be safer, as it would force”

Source location
Response from Townhead Surgery
Page 1 · response
Published 19 May 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
Escalate the referral safety concern to the Integrated Care Board and raise awareness among other practices.

Verbatim wording from the response
“We have raised this matter at a meeting held between the practice and representatives from NHS West Yorkshire Integrated Care Board on 06 June 2025. The outcome from this meeting is that we are escalating the matter to ICB level in the hope that other practices are made aware of the potential problem, but also so that the referral process can be made safer by the IT team. I enclose a copy of the letter that I have sent the ICB.”

Source location
Response from Townhead Surgery
Page 2 · response
Published 19 May 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
Operate a fortnightly internal report to identify unsent Rapid Access Chest Pain referrals.

Verbatim wording from the response
“We have had to develop our own internal safety system. This consists of a reporting system that searches all our patients for any unsent Rapid Access Chest Pain Referral. We run the report every two weeks. We have been using this since last year. So far, we have not detected any other missed referrals.”

Source location
Response from Townhead Surgery
Page 2 · response
Published 19 May 2025
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
Responsibility for the referral form and process lies with Airedale Hospital’s cardiology and IT departments, not the GP surgery.

Verbatim wording from the response
“It is important to note that the Rapid Access Chest Pain referral form and the clinical IT system in which it sits are not owned or controlled by the GP surgery. The cardiology department at Airedale hospital, together with the IT department are responsible for the form content and referral process.”

Source location
Response from Townhead Surgery
Page 1 · response
Published 19 May 2025
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised1

Failure of completed referral documents to automatically generate alerts for colleagues to action referrals

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 4

Respondent positions 1