PFD report

Michael John Halfpenny · Prevention of Future Deaths report

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Issued 1 Jun 2017•Leicester City and South Leicestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
6

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
17

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised6

  1. Failure of screening committee oversight to ensure referrals are received and actioned
    Part of recurring concern: Unreliable review and action on clinically significant incoming correspondence
  2. Failure to direct screening referrals to the vascular screening team
    Part of recurring concern: Unclear and unreliable GP access and referral pathwaysPart of recurring concern: Unreliable coordination of referrals between healthcare teams
  3. Uncertainty within general practice about the screening programme and referral criteria
    Part of recurring concern: Unclear and unreliable GP access and referral pathwaysPart of recurring concern: Unreliable coordination of referrals between healthcare teams
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. Action

    Include AAA referral and screening learning in the Leicestershire LMC newsletter.

    Stated by The Glenfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
  2. Action

    Complete and share a significant event analysis on AAA referral and screening learning.

    Stated by The Glenfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
  3. Action

    Disseminate the significant event analysis to the South Leicestershire locality GP group.

    Stated by The Glenfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable review and action on clinically significant incoming correspondence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unclear and unreliable GP access and referral pathways; Unreliable coordination of referrals between healthcare teams.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unclear and unreliable GP access and referral pathways; Unreliable coordination of referrals between healthcare teams.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably refer patients to required specialist services; Unreliable coordination of referrals between healthcare teams.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable coordination of referrals between healthcare teams.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

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
Page 6 · response
Published 4 August 2017

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

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
Page 3 · response
Published 4 August 2017

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

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
Page 9 · response
Published 4 August 2017

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

Inform GPs through the monthly newsletter about referral procedures for the Screening Programme.

Verbatim wording from the response

“In addition to the above our Head of GP Services has sent out a new communication to GPs in our monthly GP newsletter to explicitly inform them of how to refer in to the Screening Programme.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Maintain the UHL Screening Committee to oversee screening referrals, rejected cases and related incidents.

Verbatim wording from the response

“3. With respect to the UHL Screening Committee, this group was established in January 2017 to provide oversight and governance to the increasing number of national screening programmes now in place. This committee was therefore not in place at the point that the request from the GP regarding Mr Halfpenny was made to the Trust. A key function of this Committee is to review the process of referrals, the validity of rejected cases (i.e. those that fall outside the scope of the screening programme) and of course, any incidents reported relating to screening programmes. This committee will augment the rigorous quality assurance element already required for screening programmes which is monitored by the Regional Screening Group.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Deliver rolling Vascular Service awareness sessions for GPs through Protected Learning Time events.

Verbatim wording from the response

“The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 August 2017

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

Strengthen and update the imaging-referral rejection guideline with mandatory rejection reasons and CRIS documentation of referral letters.

Verbatim wording from the response

“1. We have reviewed the process for rejecting imaging within the Trust. The guideline ‘Process for the Rejection of Imaging Referrals’ is being strengthened and updated and will now include an explicit requirement that rejected referrals need to have a clear statement of why the rejection has been made and a comment must be put on CRIS (the Radiology IT system) that a rejection letter has been sent to the referrer. This is being led by our Service Manager for Imaging and it is anticipated that this guideline will be available by the end of July 2017.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 1 · response
Published 4 August 2017

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 system for redirecting incorrectly assigned imaging referrals and notifying referrers of the action and any required follow-up.

Verbatim wording from the response

“2. We have implemented a new system for redirecting any imaging referrals that inadvertently get sent to the incorrect team. The Imaging Team, led by the Clinical Director for Imaging, has provided clear instructions to their administration and clerical staff to forward screening requests to the relevant service. A rejection letter will be sent to the referrer detailing the action that has been taken and any further actions required by them.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 1 · response
Published 4 August 2017

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

Add AAA patient referral pathways to the PRISM referral-guidance system in collaboration with Primary Care colleagues.

Verbatim wording from the response

“The Vascular Service is also planning to attend GP Protected Learning Time sessions to raise awareness. This will be overseen by our AAA Screening Programme Manager, and it is anticipated that this will be a rolling programme which will have commenced by the end of July 2017. Furthermore, local GPs use a system called PRISM which is a desktop application integrated into their electronic records that provide referral guidance. Our Associate Medical Director, ████████, working in collaboration with Primary Care colleagues, will arrange for the referral pathways for AAA patients to be added onto this system so that this information can be easily accessed at the point of patient care. It is anticipated that this will also have occurred by the end of August 2017.”

Source location

2017-0174-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 August 2017

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. 1

    Share the Serious Incident investigation report with the family.

    Stated by NHS Leicester, Leicestershire and Rutland Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
  2. 2

    Share the final Serious Incident report with UHL so timescales can be added to its recommendations.

    Stated by NHS Leicester, Leicestershire and Rutland Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
  3. 3

    Send SMS advice when patients miss telephone appointments to strengthen follow-up.

    Stated by The Glenfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
  4. 4

    Display AAA screening information on waiting-room television screens.

    Stated by The Glenfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
  5. 5

    Produce and display practice posters explaining AAA screening self-referral for patients with relevant family history.

    Stated by The Glenfield SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
  6. 6

    Invoke a formal multi-agency review of the incident.

    Stated by The Glenfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
  7. 7

    Discuss the significant event analysis with the appraiser at the next appraisal.

    Stated by The Glenfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
  8. 8

    Publish AAA screening information in the Patient Participation Group newsletter.

    Stated by The Glenfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The delay in admitting the patient to casualty was beyond the general practitioners’ control.

    Stated by The Glenfield SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Share the Serious Incident investigation report with the family.

Verbatim wording from the response

“Please find enclosed the signed final report regarding the Serious Incident investigation into this case. I can confirm that we have contacted the family the share the report. UHL have already shared their findings in relation to incident 2. The final report will also be shared with UHL to add timescales to their recommendations.”

Source location

Response from East Leicestershire and Rutland Clincial Commisioning Group
Page 1 · response
Published 4 August 2017

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

Share the final Serious Incident report with UHL so timescales can be added to its recommendations.

Verbatim wording from the response

“Please find enclosed the signed final report regarding the Serious Incident investigation into this case. I can confirm that we have contacted the family the share the report. UHL have already shared their findings in relation to incident 2. The final report will also be shared with UHL to add timescales to their recommendations.”

Source location

Response from East Leicestershire and Rutland Clincial Commisioning Group
Page 1 · response
Published 4 August 2017

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

Send SMS advice when patients miss telephone appointments to strengthen follow-up.

Verbatim wording from the response

“I will alter the way I deal with failed telephone appointments to include the sending the patient an SMS message which will show advice I have given the patient in terms of following up on the missed call which should make the process much more robust.”

Source location

Response from Glenfield Surgery
Page 3 · response
Published 4 August 2017

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

Display AAA screening information on waiting-room television screens.

Verbatim wording from the response

“The screening department does not produce any appropriate communication materials with patients and the practice has taken the liberty of designing its own posters for display in the building. We have also had a discussion with our Patient Participation Group which will be including an article in the next edition of the newsletter and we are displaying the information on our television screens within the waiting areas.”

Source location

Response from Glenfield Surgery
Page 9 · response
Published 4 August 2017

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

Produce and display practice posters explaining AAA screening self-referral for patients with relevant family history.

Verbatim wording from the response

“We will produce some posters to put up in our waiting rooms to encourage any patients with a family history of aortic aneurysm to self-refer for screening and we have also mentioned this to our PPG who produce a regular newsletter for inclusion.”

Source location

Response from Glenfield Surgery
Page 3 · response
Published 4 August 2017

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

Invoke a formal multi-agency review of the incident.

Verbatim wording from the response

“I also wish to advise that I have discussed the matter with my colleagues at the CCG and this incident has been accelerated to “a serious incident” and will invoke a formal multi-agency review.”

Source location

Response from Glenfield Surgery
Page 1 · response
Published 4 August 2017

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

Discuss the significant event analysis with the appraiser at the next appraisal.

Verbatim wording from the response

“I will be discussing this SEA with my appraiser at my next appraisal.”

Source location

Response from Glenfield Surgery
Page 3 · response
Published 4 August 2017

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

Publish AAA screening information in the Patient Participation Group newsletter.

Verbatim wording from the response

“We will produce some posters to put up in our waiting rooms to encourage any patients with a family history of aortic aneurysm to self-refer for screening and we have also mentioned this to our PPG who produce a regular newsletter for inclusion.”

Source location

Response from Glenfield Surgery
Page 3 · response
Published 4 August 2017

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

The delay in admitting the patient to casualty was beyond the general practitioners’ control.

Verbatim wording from the response

“In this patient’s case the true significant event was the delay in admitting him into casualty which was unfortunate and was beyond the control of us as GPs. A poll of the clinicians in the practice was also a quick way of identifying the lack of knowledge amongst my fellow clinicians of the availability of AAA screening and the method by which patients should be referred to this service.”

Source location

Response from Glenfield Surgery
Page 2 · response
Published 4 August 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026