PFD report

Holly May Mullan · Prevention of Future Deaths report

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Issued 17 Oct 2023•Manchester South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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. Delays in access to gastroenterology and gynaecology specialist appointments
    Part of recurring concern: Excessive waiting times for specialist 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.5

  1. Action

    Implement the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  2. Action

    Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  3. Action

    Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.

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

  1. Position

    NHS England cannot investigate the relevant waiting-list pathway without further particulars.

    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

Delays in access to gastroenterology and gynaecology specialist appointments

Wider context from the report

“The inquest heard evidence of the distress caused to Holly and the impact on her health by the long waits to be seen by gastroenterologists and gynaecologists within the NHS. The evidence heard was that post-Covid, the waiting times to be seen in both specialties unless the referral was on the two-week cancer wait had grown significantly across England. As an illustration the inquest was told that pre-Covid, the average wait for a routine gynaecology referral was 18 weeks. Now in England the wait was often in excess of 12 months. Even an urgent referral would often involve a wait of over 40 weeks. This was leading to delays in diagnosis and treatment even in those with significant/severe health conditions. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for specialist referrals.

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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

Implement the national GIRFT rollout to review services, benchmark performance, develop evidence, and support elective-care recovery.

Verbatim wording from the response

“NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.”

Source location

Response from NHS England
Page 1 · response
Published 30 October 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

Enable earlier specialist advice through referral triage, advice-and-guidance, and advice-and-refer services, including direct-to-test pathways where appropriate.

Verbatim wording from the response

“As part of outpatient transformation, we are encouraging and enabling access to earlier expert advice through triage of referrals and by greater use of advice & guidance (A&G) or advice & refer (A&R) services. This allows patients and GPs to get the benefit of expert advice and treatment much earlier in the patient pathway. Patients who do not need to be seen in outpatients can continue to be safely managed in primary care, following specialist advice, or may be diverted direct to test where appropriate to facilitate an earlier diagnosis. This allows those that do not need to be seen in clinic to get access to clinic in a much shorter timescale and will help reduce referral to treatment times for all patients.”

Source location

Response from NHS England
Page 2 · response
Published 30 October 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

Expand the Further Faster Programme to additional trusts and disseminate lessons learned across the wider NHS to reduce long referral-to-treatment waits.

Verbatim wording from the response

“The GIRFT Further Faster Programme is also specifically looking at eradicating long waiting times from referral to treatment (RTT), in 16 different specialties. The specialties of Gastroenterology and Gynaecology both involved in the Further Faster Programme and have made good inroads into reducing long RTT waiting times in the first cohort of Further Faster Trusts (25 Trusts taking part), compared to the non-further faster Trusts. Of the 16 specialties involved in this programme, gastroenterology has shown the greatest impact (39% difference, as non-further faster trusts’”

Source location

Response from NHS England
Page 1 · response
Published 30 October 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

Apply the Clinical Prioritisation Programme’s clinical-review expectations to waiting lists so patients with the most urgent conditions are reviewed first.

Verbatim wording from the response

“As part of the further NHS response to COVID-19, NHS England introduced the Clinical Prioritisation Programme. This sets out an expectation of clinical review of waiting lists, to enable patients with the most urgent conditions to be reviewed first based on the information available (such as urgency indicated at referral or decision to admit, procedure type, specialty, and length of time that the patient has been waiting for treatment). The guidance was developed with the Academy Of Medical Royal Colleges.”

Source location

Response from NHS England
Page 2 · response
Published 30 October 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

Transform outpatient services by expanding patient choice and control, promoting patient-initiated follow-up, safe discharge with safety-net advice, and reduction of missed appointments.

Verbatim wording from the response

“The NHS is changing how it delivers outpatient services so that patients can be seen more quickly and can access and interact with services in a way that better suits them. We are giving patients and carers more control and greater choice over how and when they access care. We have recommended more use of patient initiated follow up (PIFU) pathways, which help empower patients to book their own follow-up care as and when they need it. We are encouraging services to discharge patients as soon as this is appropriate, with safety net advice, to reduce unnecessary follow up appointments. This allows those patients who do need to access appointments to be seen more quickly. We are helping services to reduce the number of missed outpatient appointments (did not attends or DNAs) to make the best use of all available appointments.”

Source location

Response from NHS England
Page 2 · response
Published 30 October 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

NHS England cannot investigate the relevant waiting-list pathway without further particulars.

Verbatim wording from the response

“It is not clear from your Report or from subsequent questions to your office if Holly received any diagnosis for the pain she was experiencing or if she was eventually seen by NHS gynaecologists or gastroenterologists. If she was on an admitted waiting list, but instead waiting for outpatients service her referral should have been triaged, although NHS England are not able to investigate this without further particulars. You may wish to contact the Trust to obtain further information.”

Source location

Response from NHS England
Page 2 · response
Published 30 October 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.3

  1. 1

    Discuss every Regulation 28 report through the national working group and share learning and insights across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
  2. 2

    Work with health systems and regions to establish surgical hubs and develop standardised gynaecology pathways.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
  3. 3

    Work with the RCOG and others to consider how surgical hubs can operate in gynaecology.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.

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 every Regulation 28 report through the national working group and share learning and insights across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England 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 30 October 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

Work with health systems and regions to establish surgical hubs and develop standardised gynaecology pathways.

Verbatim wording from the response

“NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.”

Source location

Response from NHS England
Page 1 · response
Published 30 October 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

Work with the RCOG and others to consider how surgical hubs can operate in gynaecology.

Verbatim wording from the response

“NHS England are also implementing the national rollout of the Getting it Right First Time (GIRFT) Programme, which is designed to improve the treatment and care of patients through reviews of services, benchmarking and developing an evidence base to support change. Through the High Volume Low Complexity programme, the GIRFT team is working with health systems and regions across England to help the NHS recover performance in elective services and reduce the backlog of patients. Gynaecology is one of six specialties being prioritised through this programme, which supports the establishment of surgical hubs for high-volume procedures and the development of standardised pathways. The GIRFT programme will work with the Royal College of Obstetricians and Gynaecologists (RCOG) and others to consider how surgical hubs can work in gynaecology as a specialty.”

Source location

Response from NHS England
Page 1 · response
Published 30 October 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