Watchdog links patient deaths to controversial NHSE policy

A watchdog has called for a pause in the rollout of NHS England’s “advice and guidance” policy to protect safety, and linked it to two patient deaths, HSJ can reveal.

The Health Services Safety Investigations Body (HSSIB) ordered a rapid review of the initiative, whose expansion is under way and forms a key part of NHSE’s waiting list reduction plan.

It said: “HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of [A&G] processes…

“Completing this evaluation and addressing findings before further expansion of advice and guidance processes, including as part of single point of access, would ensure risks to patient safety have been identified, assessed, and managed.”

A&G encourages GPs to seek specialist advice from secondary care clinicians, either before or instead of referring a patient.

HSSIB’s findings, from a review it has carried out in recent months and shared exclusively with HSJ, include strong support for A&G where it is working well. But its report says poorly designed or badly monitored implementation elsewhere is contributing to harm. 

This includes delayed and missed diagnoses, including in cancer care.

In one case it cites, a GP’s A&G request about a patient with a history of epilepsy went unanswered by a neurology team for over a month; a subsequent urgent referral then went unanswered for a further six weeks. While waiting to be triaged, the patient had a seizure at home and died of a cardiac arrest.

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Source: HSJ, 18 August 2026