PFD report

Keith Richard Gandy · Prevention of Future Deaths report

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Issued 5 Jun 2026•North London

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised2

  1. Delays in referral waiting times for specialist evaluation
    Part of recurring concern: Excessive waiting times for specialist referrals
  2. Lack of guidance to GPs on previous cancer as a red flag requiring referral for specialist opinion without waiting for further tests
    Part of recurring concern: Unreliable recognition and referral of cancer red flags
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Specialist referral waiting times are primarily the responsibility of regional commissioners and local providers, not NHS England centrally.

    Stated by NHS EnglandRedirects 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

Delays in referral waiting times for specialist evaluation

Wider context from the report

“There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests. That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months ”

Is this part of a recurring concern?

Yes — Excessive waiting times for specialist referrals.

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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

Lack of guidance to GPs on previous cancer as a red flag requiring referral for specialist opinion without waiting for further tests

Wider context from the report

“There was no guidance to GPs that underlines that previous cancer is a red flag and a referral for a specialist opinion should be made without waiting for further tests. That referral waiting times for specialist evaluation in these circumstances are between 6 months to 12 months ”

Is this part of a recurring concern?

Yes — Unreliable recognition and referral of cancer red flags.

Open source report

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

Specialist referral waiting times are primarily the responsibility of regional commissioners and local providers, not NHS England centrally.

Verbatim wording from the response

“Referral waiting times This is primarily a matter for the region and the commissioners and providers in the locality. However, we would note that in this instance, the patient was seen by the sarcoma Multi Disciplinary Team very soon after the imaging suggested the diagnosis of sarcoma. The interval between the raised alkaline phosphatase noted in primary care and his first admission was 3 weeks, and he went on to the sarcoma service rapidly thereafter.”

Source location

Response from NHS England
Page 2 · response
Published 14 August 2026

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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

Existing NICE guidance and clinicians’ recognition of previous cancer risks are considered sufficient without specific additional GP guidance.

Verbatim wording from the response

“A lack of guidance for GPs National Institute for Health and Care Excellence (NICE) guidance NG12 Suspected cancer: recognition and referral, advises that clinicians use judgement when symptoms present in people with higher baseline cancer risk. Whilst it does not specifically list previous cancer as a red flag, a history of cancer is widely recognised clinically as such a factor.”

Source location

Response from NHS England
Page 1 · response
Published 14 August 2026

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.2

  1. 1

    Share a copy of the response with the Central East Integrated Care Board to support broader learning from the case.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
  2. 2

    Discuss all received Regulation 28 reports through the national Regulation 28 Working Group to share learning and insights across NHS regions.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.

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

  1. 1

    The practice’s review found no specific patient-safety issues requiring further practice action and considered care consistent with appropriate guidance.

    Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 a copy of the response with the Central East Integrated Care Board to support broader learning from the case.

Verbatim wording from the response

“The ICB have advised that they have been assured that the practice has reviewed the case through its Significant Event learning process, has considered whether any patient safety issues were identified and has shared the learning within the practice. The ICB will also consider the broader learning from this case, particularly around persistent or evolving pain symptoms, previous cancer history, clinical reassessment and escalation, can be shared through appropriate primary care quality and patient safety routes. NHS England will share a copy of our response to your Report with the ICB to support this.”

Source location

Response from NHS England
Page 2 · response
Published 14 August 2026

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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

Discuss all received Regulation 28 reports through the national Regulation 28 Working Group to share learning and insights across NHS regions.

Verbatim wording from the response

“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 events, such as the sad death of Mr Gandy, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 14 August 2026

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 practice’s review found no specific patient-safety issues requiring further practice action and considered care consistent with appropriate guidance.

Verbatim wording from the response

“Regional response Central East Integrated Care Board (ICB) have advised that the practice has confirmed that Mr Gandy’s care was reviewed through a formal Significant Event learning meeting as part of an internal practice learning session. The practice has confirmed that its review did not identify any specific patient safety issues requiring further action by the practice and that, overall, the care provided was considered to have followed appropriate clinical guidance.”

Source location

Response from NHS England
Page 2 · response
Published 14 August 2026

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