Recurring concern

Unreliable access to regional neonatology specialist support

First to latest report 25 Apr 2022 — 30 Aug 2024

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 4

What this concern includes

Includes failures of the regional neonatology support arrangement, including absent routes for cross-regional specialist advice and unreliable or delayed on-call consultant availability across covered hospitals.

What is not included

Excludes generic regional coordination or mutual-aid deficiencies not explicitly tied to neonatology specialist support.
Excludes failures involving other clinical specialties, ambulance transfers, radiology sharing or general referral capacity.
Excludes isolated staffing, training, communication or equipment deficiencies unless they directly impair access to the regional neonatology support arrangement.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

British Association of Perinatal Medicine1

NHS England1

Sheffield Teaching Hospitals NHS Foundation Trust1

University Hospitals Sussex NHS Foundation Trust1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

30 Aug2024
West Sussex, Brighton and Hove
Concerns raised1
1. Variability in on-call Neonatology Consultant attendance times
Linked responses

British Association of Perinatal Medicine
NHS England
University Hospitals Sussex NHS Foundation Trust
Stated actions 4
1. University Hospitals Sussex NHS Foundation Trust
  Explore options for establishing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit.
2. University Hospitals Sussex NHS Foundation Trust
  Approach the Integrated Care Board about externally reviewing current arrangements and options to strengthen Neonatal Consultant on-call provision for the Princess Royal Hospital service.
3. British Association of Perinatal Medicine
  Recommend against simultaneous out-of-hours cover of geographically separate neonatal sites and concurrent Tier 2 and Tier 3 cover by one consultant.
1. British Association of Perinatal Medicine
  Publish recommendations requiring immediate consultant availability, attendance within 30 minutes, and robustly job-planned and risk-assessed local coverage arrangements.
Respondent positions 7
1. University Hospitals Sussex NHS Foundation Trust
  Outcome reviews found no evidence that the current Neonatal Consultant on-call arrangements at Princess Royal Hospital are unsafe or contribute to neonatal deaths.
  Disputes the concern
1. University Hospitals Sussex NHS Foundation Trust
  The Trust cannot currently provide a separate Princess Royal Hospital rota because Consultant, workforce and financial resources are unavailable.
  Unable to act
2. University Hospitals Sussex NHS Foundation Trust
  The Trust is asking the Integrated Care Board to externally review current arrangements and options for strengthening Neonatal Consultant on-call provision.
  Redirects responsibility
3. NHS England
  NHS Trusts determine their own out-of-hours neonatal consultant response-time policies under consultants’ terms and conditions.
  Redirects responsibility
4. British Association of Perinatal Medicine
  BAPM guidance contains no recommendation specifying the time consultants must be on site.
  Disputes the concern
5. British Association of Perinatal Medicine
  BAPM is advisory rather than executive and therefore cannot direct trusts' local implementation processes.
  Outside remit
6. British Association of Perinatal Medicine
  Individual trusts are responsible for implementing local processes in line with national guidelines.
  Redirects responsibility
AI-generated summary

Felix Burton HARTLEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Felix Burton Hartley was born without a heartbeat on 19 February 2023, was resuscitated after around 20 minutes without a heartbeat, and later could not recover from hypoxia and chorioamnionitis. The concern was that variable attendance times for the on-call Neonatology Consultant, covering two geographically separated hospitals, could create a risk of future deaths, although the report did not find the consultant’s attendance time causative or contributory to Felix’s death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Variability in on-call Neonatology Consultant attendance times
Wider context from the report
“In this case, I heard that over the weekend and overnight Neonatology Consultants are not available immediately on site at either the Princess Royal Hospital, Haywards Heath or the Royal Sussex County Hospital in Brighton. I heard that on-call Consultants over the weekend are on site at Brighton for some of the period but for the majority they are contactable by telephone in the first instance only. I heard that the Trust position is that this is not unusual in many settings as Consultants are not intended to be the first responders to emergency calls. At University Hospitals Sussex NHS Foundation Trust (“the Trust”), the on-call Consultant covers both the Princess Royal Hospital and the Royal Sussex County Hospital. These two sites are not close in proximity, and I heard that the traffic impacts on the time it would take for a Consultant to attend. The on-call Consultant does not always have access to an emergency vehicle and if called to attend either site would use their own vehicle and be subject to the usual road traffic laws. I heard that the Trust practice, as opposed to Policy, is that the on-call Consultant cannot be more than 30 minutes from either Brighton or Haywards Heath. The Trust facilitates accommodation at Brighton for the on-call Consultant so that they are within 30 minutes of Brighton if required. I was told that the arrangements for Neonatal care at the Princess Royal are in accordance with the British Association of Perinatal Medicine guidelines and that there is no national guidance as to the time that an on-call Neonatology Consultant should be expected to attend a hospital in the event of an emergency or as to whether multiple sites can be covered by one on-call Consultant. Whilst I did not find the timing of the attendance of the on-call Consultant causative or contributory in relation to Felix’s death, I am concerned that the time period in which attendance is made may vary and create a risk of future deaths. ”
Source location
Felix Burton HARTLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Explore options for establishing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit.

Verbatim wording from the response
“The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the current British Association of Perinatal Medicine standards, but our review of outcomes did not find evidence that the current arrangements we have in place are unsafe. However, it is acknowledged that it is right to review these arrangements. We are exploring the options for providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit, but we do not have existing Consultant resources to meet this need.”

Source location
Response from University Hospitals Sussex
Page 3 · response
Published 2 September 2024
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
Approach the Integrated Care Board about externally reviewing current arrangements and options to strengthen Neonatal Consultant on-call provision for the Princess Royal Hospital service.

Verbatim wording from the response
“The Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce and financial resources are not currently available to fund the large Consultant expansion that would be needed to provide a freestanding Princess Royal Hospital Special Care Baby Unit rota. Therefore, in view of the complexity and interdependency of the provision of maternity services, the Trust is approaching the Integrated Care Board (ICB) to consider externally reviewing the current arrangements and the options for strengthening our Neonatal Consultant on-call arrangements for the Princess Royal Hospital Neonatal service.”

Source location
Response from University Hospitals Sussex
Page 3 · response
Published 2 September 2024
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
Recommend against simultaneous out-of-hours cover of geographically separate neonatal sites and concurrent Tier 2 and Tier 3 cover by one consultant.

Verbatim wording from the response
“In our Service and Quality Standards for Provision of Neonatal Care in the UK (November 2022) [Page 24] we recommend;”

Source location
Response from British Association of Perinatal Medicine
Page 1 · response
Published 2 September 2024
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
Publish recommendations requiring immediate consultant availability, attendance within 30 minutes, and robustly job-planned and risk-assessed local coverage arrangements.

Verbatim wording from the response
“In a new document from November 2023 that was NOT in place at the time of this death, Consultant Working Patterns – A BAPM Report [page 5]”

Source location
Response from British Association of Perinatal Medicine
Page 1 · response
Published 2 September 2024
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
Outcome reviews found no evidence that the current Neonatal Consultant on-call arrangements at Princess Royal Hospital are unsafe or contribute to neonatal deaths.

Verbatim wording from the response
“Neonatal deaths are reviewed at a regional level and local data is benchmarked by MBRRACE. These reviews of neonatal deaths have not highlighted the availability of the Neonatal Consultant at the Princess Royal Hospital as a contributory factor to neonatal deaths.”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 2 September 2024
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 Trust cannot currently provide a separate Princess Royal Hospital rota because Consultant, workforce and financial resources are unavailable.

Verbatim wording from the response
“The Trust is aware that the current Neonatal Consultant on-call arrangements for the Trevor Mann Baby Unit and the Princess Royal Hospital Special Care Baby Unit do not meet the current British Association of Perinatal Medicine standards, but our review of outcomes did not find evidence that the current arrangements we have in place are unsafe. However, it is acknowledged that it is right to review these arrangements. We are exploring the options for providing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit, but we do not have existing Consultant resources to meet this need.”

Source location
Response from University Hospitals Sussex
Page 3 · response
Published 2 September 2024
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 Trust is asking the Integrated Care Board to externally review current arrangements and options for strengthening Neonatal Consultant on-call provision.

Verbatim wording from the response
“The Trevor Mann Baby Unit Consultants are already fully committed clinically, and the workforce and financial resources are not currently available to fund the large Consultant expansion that would be needed to provide a freestanding Princess Royal Hospital Special Care Baby Unit rota. Therefore, in view of the complexity and interdependency of the provision of maternity services, the Trust is approaching the Integrated Care Board (ICB) to consider externally reviewing the current arrangements and the options for strengthening our Neonatal Consultant on-call arrangements for the Princess Royal Hospital Neonatal service.”

Source location
Response from University Hospitals Sussex
Page 3 · response
Published 2 September 2024
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 Trusts determine their own out-of-hours neonatal consultant response-time policies under consultants’ terms and conditions.

Verbatim wording from the response
“NHS Trusts exercise their own policies for out of hours, on call response times. This is linked to the Terms and Conditions for all NHS Consultants. My colleagues in the South East have been asked to engage with University Hospitals Sussex NHS Foundation Trust and Sussex Health and Care Integrated Care Board on the concerns raised in your Report for assurance purposes. NHS England will also consider the Trust’s responses to your Report carefully in due course.”

Source location
Response from NHS England
Page 2 · response
Published 2 September 2024
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
BAPM guidance contains no recommendation specifying the time consultants must be on site.

Verbatim wording from the response
“The national terms and conditions for NHS consultants in England are set by NHS Employers and we have attached the latest version [Please see p18 and 40.] We have also attached A guide to Determining On-call Availability Supplements issued by the NHS Modernisation Agency (August 2004). There is no recommendation around the time required to be on site.”

Source location
Response from British Association of Perinatal Medicine
Page 1 · response
Published 2 September 2024
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
BAPM is advisory rather than executive and therefore cannot direct trusts' local implementation processes.

Verbatim wording from the response
“BAPM is an advisory, not an executive body. We have made some relevant recommendations that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines.”

Source location
Response from British Association of Perinatal Medicine
Page 1 · response
Published 2 September 2024
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
Individual trusts are responsible for implementing local processes in line with national guidelines.

Verbatim wording from the response
“BAPM is an advisory, not an executive body. We have made some relevant recommendations that can form the basis for local guidance. It is the responsibility of individual trusts to implement their own processes in line with national guidelines.”

Source location
Response from British Association of Perinatal Medicine
Page 1 · response
Published 2 September 2024
Open published response
25 Apr2022
South Yorkshire (Western)
Concerns raised1
1. Lack of access to support from regional neonatology colleagues
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Cassian Curry · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Cassian Curry was born at 28 weeks gestation and died after an umbilical venous catheter was left in a suboptimal position and was not reviewed as planned. The inquest found that the plan to review and pull back the line was not adequately recorded or communicated, including to the care team and Cassian’s parents, and that this contributed to his death. Concerns included staffing burden, the design and suitability of documentation forms, and access to wider regional neonatal support.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of access to support from regional neonatology colleagues
Wider context from the report
“4. I heard about the Jessops Unit having responsibility, not only for babies already in the unit but also for some of the sickest and most premature babies in the region. I did not hear any evidence of how the Jessops Unit accesses support from colleagues across the region. I heard evidence of trying to access colleagues to support the Jessops Unit directly and a buddy system but there are other neonatology consultants across the Region who could provide remote assistance potentially if encouraged to think as a system. ”
Source location
Cassian Curry · Prevention of Future Deaths report
Page 3 · concerns
Open source report