Serena Roberts

1. 1. delays in secondary care gynaecology appointments

   “significant delays in patients being seen in secondary care for gynaecological referrals from GPs”

2. 2. misapplication of NICE guidance on heavy menstrual bleeding

   “understanding and application of the NICE guidance on heavy premenstrual bleeding in General Practice was a factor in recognising the risk to her health”

3. 3. inadequate referral documentation

   “quality of the documentation in the referral to secondary care form the GP was poor and the inquest was told that this hampered the triage of her case by secondary care”

4. 4. absence of referral follow up systems

   “no evidence available that GP practices had clear systems of follow up in relation to referrals to identify where they had not taken place or identify if the risk had increased and to escalate the referral”

No published response was found on judiciary.uk.