Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder and contributes to excess morbidity and mortality in the populations affected. In developed healthcare systems PHPT is routinely diagnosed at the asymptomatic stage. Parathyroidectomy is the only curative treatment. The latest guidelines specific to the surgical management of patients with asymptomatic PHPT have been developed by the Fourth International Workshop. This audit aimed to establish how many of the new patient referrals with a clinical diagnosis of asymptomatic PHPT seen in the Metabolic Bone clinic at UHB tertiary care centre between 2015 and 2017 were referred for surgery in accordance with the Fourth International Workshop Guidelines. The clinical referral letters of all 216 patients with a confirmed diagnosis of PHPT were screened to find asymptomatic patients with sufficient data for analysis. 89 patients met this criteria. 21 patients with asymptomatic PHPT were referred for surgery. 76% were referred in accordance with the international guidelines. Of those patients not referred for surgery, 52.80% met at least one of the Fourth International Workshop criteria for surgery. In a significant minority of these cases,15%, the reason for non-referral to surgery was unclear. A proportion of patients in this category were aged <50 years and would be at highest risk of end organ damage resulting from hypercalcaemia. This audit demonstrates that adherence to international guidelines regarding the surgical management of patients with asymptomatic PHPT is suboptimal. It highlights the need for the implementation of comprehensive, standardised local protocols to improve this. Despite the subsequent publication of the May 2019 NICE guidelines on the diagnosis, management and initial assessment of patients with hyperparathyroidism, the requirements suggested in this audit specific to patients with asymptomatic PHPT require further consideration.