PFD report

Richard James MOSS · Prevention of Future Deaths report

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Issued 25 Apr 2025•North Yorkshire and York

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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

  1. Action

    Review the referral process through a significant event meeting to identify failures and prevent recurrence.

    Stated by Townhead SurgeryStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
  2. Action

    Request removal of the GP Assist option that allows referral forms to be sent without a secretarial alert.

    Stated by Townhead SurgeryStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
  3. Action

    Escalate the referral safety concern to the Integrated Care Board and raise awareness among other practices.

    Stated by Townhead SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.

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

  1. Position

    Responsibility for the referral form and process lies with Airedale Hospital’s cardiology and IT departments, not the GP surgery.

    Stated by Townhead SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

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

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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

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

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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

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

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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
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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