PFD report

Nicholas John PENNICOTT · Prevention of Future Deaths report

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Issued 11 May 2023•West Sussex, Brighton and Hove

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
2

Of 1 recipient

Stated actions
15

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 raised3

  1. Long-term vacancy of a substantive neurology consultant post
    Part of recurring concern: Insufficient neurology service capacity for timely specialist assessment
  2. Delays in neurology outpatient appointments
    Part of recurring concern: Insufficient neurology service capacity for timely specialist assessment
  3. Gaps in neurology service provision
    Part of recurring concern: Insufficient neurology service capacity for timely specialist assessment
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.11

  1. Action

    Provide three weekly consultant neurologist sessions for GP advice and guidance before or instead of outpatient referral.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  2. Action

    Monitor the waiting list and review urgent patients awaiting appointments to support prioritisation.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  3. Action

    Provide more than 600 additional outpatient appointments through Elective Services over 12 weeks.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.

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

  1. Position

    Implementing recommended acute neurology outpatient clinics is constrained by workforce shortages.

    Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Long-term vacancy of a substantive neurology consultant post

Wider context from the report

“During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service. There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital. The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision. The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment. ”

Is this part of a recurring concern?

Yes — Insufficient neurology service capacity for timely specialist assessment.

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

Delays in neurology outpatient appointments

Wider context from the report

“During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service. There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital. The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision. The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment. ”

Is this part of a recurring concern?

Yes — Insufficient neurology service capacity for timely specialist assessment.

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

Gaps in neurology service provision

Wider context from the report

“During the course of the evidence the Hospital explained that long waiting times for neurology outpatient appointments was a persistent challenge for the Trust due to capacity issues within the neurology service. There had been a long-term vacancy, of three years, within the neurology service for a substantive neurology consultant at the hospital. The Inquest was told that there was a national shortage of neurologists. The Trust had relied on long term locum consultants, leading to some short-term gaps in provision. The shortage of Neurologists nationally and the capacity issues within the neurology service at the Hospital led to a missed opportunity for Mr PENNICOTT to receive earlier specialist assessment. ”

Is this part of a recurring concern?

Yes — Insufficient neurology service capacity for timely specialist assessment.

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

Provide three weekly consultant neurologist sessions for GP advice and guidance before or instead of outpatient referral.

Verbatim wording from the response

“Advice and Guidance service for GPs”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 17 May 2023

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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

Monitor the waiting list and review urgent patients awaiting appointments to support prioritisation.

Verbatim wording from the response

“• We have introduced regular monitoring of the waiting list, with reviews of urgent patients waiting to be seen to allow appropriate prioritisation within available clinic capacity”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Provide more than 600 additional outpatient appointments through Elective Services over 12 weeks.

Verbatim wording from the response

“• We have engaged Elective Services to provide additional outpatient capacity to address waiting times for new patients and anticipate that these measures will reduce waiting times for all patients. Elective Services are providing in excess of 600 outpatient appointments over a 12-week period”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Implement cross-site management changes offering alternative-site appointments to reduce maximum outpatient waiting times.

Verbatim wording from the response

“• We are implementing changes to manage the demand for new outpatient appointments across the 3 sites within the Trust to reduce the maximum waiting time for patients across Sussex, offering patients appointments at alternative sites to reduce waiting time”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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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

Continue developing the advanced clinical practice model in neurology with clinical nurse specialists across general and specialist services.

Verbatim wording from the response

“• We continue to develop our model of advanced clinical practice in neurology with a team of clinical nurse specialists working in general neurology as well as in specialist areas, including headache, epilepsy and Parkinson’s disease. We have developed a proposal to increase the capacity of the services that ACPs are providing and expect to deliver this in the second half of this financial year”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Maintain a weekday standard operating plan for emergency consultants to obtain consultant neurologist advice.

Verbatim wording from the response

“Advice and guidance for hospital consultants”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Increase advanced clinical practitioner service capacity under the developed proposal.

Verbatim wording from the response

“• We continue to develop our model of advanced clinical practice in neurology with a team of clinical nurse specialists working in general neurology as well as in specialist areas, including headache, epilepsy and Parkinson’s disease. We have developed a proposal to increase the capacity of the services that ACPs are providing and expect to deliver this in the second half of this financial year”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Update outpatient referral triage criteria and introduce a pre-screen for previously known patients.

Verbatim wording from the response

“• Patients referred for outpatient clinic are triaged by a consultant neurologist and categorised by clinical urgency based on the information provided by the GP”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Employ a locum consultant neurologist to provide additional outpatient clinics and consultant triage.

Verbatim wording from the response

“• We have now employed a locum consultant neurologist to support the service and provide additional outpatient clinics and consultant triage. This arrangement is ongoing”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Advertise substantive consultant neurologist posts.

Verbatim wording from the response

“• We have advertised for substantive consultant neurologists. The advert closes on 26th July and we look forward to shortlisting any applicants”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 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

Publish the NHS Long Term Workforce Plan to grow, retain and reform the NHS workforce.

Verbatim wording from the response

“Last month, NHS England published the NHS Long Term Workforce Plan, setting out our plans to grow, retain and reform our workforce across the next fifteen years. This plan looks to reduce the national shortages we see across the NHS, helping to provide safe and timely access to urgent care that will reduce the delays currently being faced by patients such as Nicholas.”

Source location

Response from NHS England
Page 2 · response
Published 17 May 2023

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

Implementing recommended acute neurology outpatient clinics is constrained by workforce shortages.

Verbatim wording from the response

“Your Report also raises a concern that there is a shortage of neurologists at a national level. This is a well-recognised issue within the NHS and there is currently significant variation in neurologist numbers across England. The Getting It Right First Time (GIRFT) programme for neurology (GIRFT is a national NHS England programme designed to improve the treatment and care of patients through clinically led reviews) recommends that all acute hospitals have acute neurology liaison services in place, and, ideally, acute neurology outpatient clinics to urgently see rapidly deteriorating patients. However, this is dependent on workforce constraints.”

Source location

Response from NHS England
Page 2 · response
Published 17 May 2023

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.4

  1. 1

    Introduce the e-RS system to manage neurology referrals.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
  2. 2

    Update the neurology Directory of Services to identify the advice and guidance facility and specialist clinics.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  3. 3

    Disseminate primary-care communications about the GP advice and guidance facility.

    Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
  4. 4

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.

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

  1. 1

    At weekends, hospital consultants can obtain neurology advice from on-call teams at Southampton General Hospital or Royal Sussex County Hospital.

    Stated by University Hospitals Sussex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Introduce the e-RS system to manage neurology referrals.

Verbatim wording from the response

“The service introduced the new e-RS system for managing referrals on 2nd May 2023.”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 17 May 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

Update the neurology Directory of Services to identify the advice and guidance facility and specialist clinics.

Verbatim wording from the response

“• A wider communication with primary care updating on developments has been written to increase awareness amongst GPs of this facility and we expect this to be shared in the primary care newsletter published by the ICB in August”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 17 May 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

Disseminate primary-care communications about the GP advice and guidance facility.

Verbatim wording from the response

“• GPs can select the advice and guidance dropdown option when they are using ERS to refer patients. We are now receiving up to 10 requests per week so are confident that GPs are aware of this service and able to access it”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 1 · response
Published 17 May 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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHSE work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 17 May 2023

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

At weekends, hospital consultants can obtain neurology advice from on-call teams at Southampton General Hospital or Royal Sussex County Hospital.

Verbatim wording from the response

“• A Standard Operating Plan (SOP) is in place for the Emergency Department / Emergency Floor consultants to access advice from a consultant neurologist on weekdays. At weekends, advice can be sought from the on-call neurology teams at Southampton General Hospital or Royal Sussex County Hospital”

Source location

Response from Universityt Hospitals Sussex NHS Foundation Trust
Page 2 · response
Published 17 May 2023

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