Recurring concern

Delays in consultant review of patients

First to latest report 24 Sep 2013 — 27 Feb 2026

Reports that mention this concern
35
Times this concern has been raised
37
Stated actions linked to this concern
32

What this concern includes

Includes reports identifying delayed, missed or insufficiently timely consultant review of patients, including failures to seek or arrange an early consultant review where consultant input is required.

What is not included
  • Excludes delays in non-consultant consultations, referrals or specialist services unless the report specifically concerns consultant review.
  • Excludes failures involving only documentation, communication, continuity, staffing or on-call cover when delayed consultant review is not itself identified.
  • Excludes concerns about the quality or appropriateness of consultant decisions where timely review was not a material issue.

Reports and published responses 35 reports

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

  1. Warwickshire

    AI-generated summary

    Carol Ann Welch · 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

    Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.

    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 familiarity with guidance requiring consultant discussion of unexpected returns within 72 hours

    Wider context from the report

    “(1) The subsequent investigation by GEH highlighted two areas which needed addressing: • The need to raise awareness of subarachnoid haemorrhage masquerading as a migraine and the need to investigate possible neurological findings. This had been done by means of discussions in meetings and a poster displayed in a staff area. • Doctors were not familiar with the Royal College Guidance that there is a need to discuss with a consultant, all patients who unexpectedly return within 72 hours of discharge from the emergency department. This had been done by circulating an aide memoire to be given to those in training and existing members of the department. ”

    Source location

    Carol Ann Welch · 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

    Work with Information Technology to add a 72-hour reattendance alert requiring consultant advice before discharge.

    Verbatim wording from the response

    “The Trust has, however, noted that the middle grade doctor in question did not follow the appropriate guidance of referring to a consultant if a patient returns to the department within 72 hours with the same clinical condition. The Trust is currently working with its Information Technology Department to add an alert to the Clinical Portal used by UEC to flag/highlight if the patient reattends within 72 hours and mandate that the doctor should seek advice from a consultant prior to discharging the patient from the department. We believe this additional safety measure would prevent future harm in this group of patients who are at higher risk.”

    Source location

    Response from George Eliot Hospital
    Page 4 · response
    Published 16 January 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

    Audit patients reattending within 72 hours for consultant referral before discharge and share the findings within UEC and at Trust-wide Audit Day.

    Verbatim wording from the response

    “UEC are in the process of conducting an audit to review patients that have reattended within 72 hours to see whether they were referred to a consultant prior to discharge. The outcome of this review will be shared within UEC and will also be presented at the Trust Wide Audit Day.”

    Source location

    Response from George Eliot Hospital
    Page 4 · response
    Published 16 January 2023

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    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

    Overseas-qualified doctors undergo Royal College accreditation, including assessment of familiarity with relevant guidance, on the same basis as UK-trained doctors.

    Verbatim wording from the response

    “When the Trust receives an application from a doctor our People and Recruitment Department will check the official GMC registration to ensure the doctor is appropriately registered and holds the relevant qualifications and license to practice in the UK. The doctor in Mrs Welch’s case was registered with the GMC in April 2020. In addition, this doctor became a member of the Royal College of Emergency Medicine before they started working at this Trust in September 2020. Accordingly, the doctor will have been assessed as competent by the Royal College as part of their registration and accreditation process in exactly the same way a UK trained doctor would be assessed. This accreditation includes an assessment of familiarity with relevant Royal College guidance.”

    Source location

    Response from George Eliot Hospital
    Page 2 · response
    Published 16 January 2023

    Open published response

  2. Cumbria

    AI-generated summary

    Gordon Bernard Hendley · 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

    Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

    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

    Delays in medical consultant review of patients referred to medicine

    Wider context from the report

    “3) Gordon had a CT scan, he was referred to medicine but not seen by a medical consultant until 4.30 pm, he was to be admitted to a ward (this happened at 6.30pm) but there is no record in the notes of the significance of the earlier blood test being appreciated. ”

    Source location

    Gordon Bernard Hendley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Freda Mary Lennox · 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

    Freda Mary Lennox, an 86-year-old woman with significant idiopathic pulmonary fibrosis and other medical comorbidities, was admitted for an elective total hip replacement and died on 4 November 2020 after experiencing a cardio-respiratory arrest at the end of the procedure. Concerns included incomplete pre-operative assessment, a lack of recent orthopaedic and anaesthetic review before admission, and inadequate resources for a dedicated high-risk anaesthetic assessment service.

    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

    Failure to provide recent consultant orthopaedic review before admission for elective surgery

    Wider context from the report

    “2. Mrs Lennox had not been recently reviewed by the consultant orthopaedic surgeon prior to her admission on 2nd November 2020 despite her medical co-morbidities having given rise to concerns as to her suitability for an elective total hip replacement. ”

    Source location

    Freda Mary Lennox · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 Consultant involvement after admission

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · 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

    Provide a Non-Medical Approved Clinician role with programmed senior medical support, supervision and education for ward care.

    Verbatim wording from the response

    “Lucy Wade ward is staffed by two consultants, Dr ████████, Consultant Clinical Psychologist and Dr ████████, Consultant Psychiatrist. Dr ████████ is a fully qualified approved clinician under the Mental Health Act. This is a new role, known as a Non-Medical Approved Clinician or also known as Multi Professional Approved Clinician. In order for medical aspects of inpatient care to be fully provided Dr ████████ has a programmed activity in his job plan to support them. They have a regular Tuesday meeting to discuss her patients, and he sees some of her patients directly if indicated. He provides senior medical input if needed during the rest of the week. He also supervises the clinical work and education of the junior medical staff on the ward.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 4 · response
    Published 24 January 2022

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    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

    Available consultant psychiatrist support was not accessed because clinicians considered it unnecessary at the time.

    Verbatim wording from the response

    “Dr ████████ or Dr ████████ could have accessed consultant psychiatrist support at this point in time from Dr ████████. They did not do so as, at the time, they did not think this was necessary. Unfortunately, Mrs Whitehead had suffered the respiratory arrest and had been transferred before the face-to-face consultant review could take place.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 5 · response
    Published 24 January 2022

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Jacob · 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

    Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.

    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 named or responsible consultant review before child discharge

    Wider context from the report

    “2. Lack of Named/Responsible Consultant review prior to a child’s discharge ”

    Source location

    Jacob · Prevention of Future Deaths report
    Page 2 · concerns

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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

    Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.

    Verbatim wording from the response

    “• In addition to the audit process, the Divisional Director of Nursing for Children & Neonates and the Matron for Children’s Services have developed an assurance tool, which is being completed weekly for a period of 12 weeks, auditing approximately 5 sets of clinical records every week from each acute area. Unlike the sepsis audit the assurance tool is not exclusive to patients with a clinical diagnosis of sepsis. The tool is designed to monitor the following which were areas of concern noted at the inquest:”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 3 · response
    Published 3 August 2021

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    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

    Consultant handovers, case discussion and retrospective attendance-note review provide sufficient safeguards for children discharged without admission.

    Verbatim wording from the response

    “All admitted paediatric patients are discussed with the consultant on service at each morning and evening handover as a routine practice across both sites, therefore, all admitted children are reviewed regularly by a Consultant during their admission. Patients referred that are deemed not to require admission following assessment by the ST4-8 Junior Doctor may be discussed with/reviewed by the Consultant of the week”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 5 · response
    Published 3 August 2021

    Open published response

  6. Surrey

    AI-generated summary

    MARY NABILIA GWANYAMA · 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

    Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

    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 mandated face-to-face consultant psychiatrist review after acute-unit discharge

    Wider context from the report

    “2. Mary was not subject to a medical review from the 28th March 2018 to the 26th May 2018. There is no policy in place which mandates when or if a patient should be subject to face to face review by a consultant psychiatrist after discharge from the acute unit. ”

    Source location

    MARY NABILIA GWANYAMA · Prevention of Future Deaths report
    Page 4 · concerns

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    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

    Medical review decisions remain risk- and needs-led through multidisciplinary processes rather than being governed by a fixed post-discharge Consultant Psychiatrist review mandate.

    Verbatim wording from the response

    “Senior clinicians within the Trust have considered this issue, and our need to be agile to respond to people with differing needs. For that reason, the decision as to whether a person under HTT requires a medical review is risk and needs led within the context of a multi-disciplinary approach which includes a Consultant Psychiatrist. (It should however be noted that it is already mandated that a patient must follow up with community services within 72 hours of discharge from hospital, within an overall multi-disciplinary approach.)”

    Source location

    2021-0117-Response-from-Surrey-and-Borders-Partnership-NHS-Foundation-Trust-Redacted
    Page 2 · response
    Published 23 April 2021

    Open published response

  7. Suffolk

    AI-generated summary

    Karen Jane Winn · 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

    Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.

    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

    Failure to escalate serious or rare blood-condition diagnoses for Haematology Consultant input

    Wider context from the report

    “1. I am concerned that a differential diagnosis of a rare and serious blood condition (haemolytic anaemia), although identified soon after admission, was not escalated to a Haematology Consultant at the time this diagnosis was made. It was a rare condition, which by its very nature should be treated with the support of haematology specialists. I am concerned that those specialist were unaware that a differential diagnosis of serious blood disorder had been made without their specialist input. ”

    Source location

    Karen Jane Winn · 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

    Establish and publish an autoimmune haemolytic anaemia flow pathway covering investigations, treatment and referral to the haematology on-call consultant.

    Verbatim wording from the response

    “A meeting was convened with the Haematology Consultants to consider how escalation is achieved and how we can ensure that this is robust. Whilst there are specific criteria for the treatment of Autoimmune Haemolytic Anaemia, it is acknowledged that this is a rare condition. A flow pathway for Autoimmune Haemolytic Anaemia has been established, identifying investigations and treatment required, inclusive of referring to the haematology on call consultant. This flow pathway has been published on the Trust’s ‘Pink Book’, a clinical reference point for all clinical staff, both internally and within the community (including GPs). This pathway will also be included in the ‘Heads Up book’ (HUB) which is currently being developed.”

    Source location

    2020-0213-Response-from-West-Suffolk-Hospital-REDACTED.pdf
    Page 1 · response
    Published 4 December 2020

    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

    Include the autoimmune haemolytic anaemia flow pathway in the developing Heads Up book for junior clinicians.

    Verbatim wording from the response

    “A meeting was convened with the Haematology Consultants to consider how escalation is achieved and how we can ensure that this is robust. Whilst there are specific criteria for the treatment of Autoimmune Haemolytic Anaemia, it is acknowledged that this is a rare condition. A flow pathway for Autoimmune Haemolytic Anaemia has been established, identifying investigations and treatment required, inclusive of referring to the haematology on call consultant. This flow pathway has been published on the Trust’s ‘Pink Book’, a clinical reference point for all clinical staff, both internally and within the community (including GPs). This pathway will also be included in the ‘Heads Up book’ (HUB) which is currently being developed.”

    Source location

    2020-0213-Response-from-West-Suffolk-Hospital-REDACTED.pdf
    Page 1 · response
    Published 4 December 2020

    Open published response

  8. Manchester South

    AI-generated summary

    Evelyn Ross · 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

    Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

    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 a clear system of regular orthogeriatric consultant reviews

    Wider context from the report

    “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration. ”

    Source location

    Evelyn Ross · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate deterioration to a consultant

    Wider context from the report

    “5. There did not appear to be a clear system of regular orthogeriatric consultant reviews of Mrs Ross. This meant that there was no escalation of her condition to a consultant when she began to show signs of deterioration. ”

    Source location

    Evelyn Ross · 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

    Provide daily and twice-weekly Consultant in Care of the Elderly reviews, with escalation to senior medical staff for clinical concerns and cover arrangements for unavailable consultants.

    Verbatim wording from the response

    “The Consultants in Care of the Elderly/Geriatricians at Trafford General Hospital input daily at the morning Board Rounds and all patients are discussed and followed up to Consultant level as needed. If clinical concerns are raised in respect of an individual patient’s case, a member of the Senior Medical team (Consultant or Registrar) will review the patient.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 9 · response
    Published 5 June 2020

    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 concluded that regular Consultant reviews occurred and junior doctors escalated clinical concerns as required in Mrs Ross’ case.

    Verbatim wording from the response

    “Having undertaken a comprehensive review of the entries in Mrs Ross’ clinical notes, the Consultant team at Trafford General Hospital have been able to establish that in Mrs Ross’ case there were in fact regular Consultant reviews, in line with required standards, and there was no issue in respect of junior doctor escalation, which as documented in the clinical notes took place as required. I apologise if the evidence you heard at the Inquest did not accurately convey this.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 9 · response
    Published 5 June 2020

    Open published response

  9. East London

    AI-generated summary

    Mrs Ibiyemi Ereohah · 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

    Mrs Ibiyemi Ereohah attended hospital with abdominal pain and anaemia, and investigations concerning a possible sarcoma were followed by delays and deficiencies in assessment and surgical planning. She underwent a hysterectomy on 30 August 2018 and was subsequently diagnosed with a high-grade uterine sarcoma; she died from metastatic leiomyosarcoma on 17 September 2018. The substantive concerns included inadequate gynae-oncology consultant cover and a delayed consultant review of her fitness for surgery.

    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

    Failure to ensure timely consultant reviews

    Wider context from the report

    “2. Mrs Ereohah was deemed unfit for surgery by a clinical nurse specialist on the 16th February 2018. The nurse requested a consultant review which should have taken place within 3-5 weeks. It did not take place until 16 weeks later. The Inquest heard evidence that there was no system in place to ensure that all consultant reviews were carried out within a timely manner. ”

    Source location

    Mrs Ibiyemi Ereohah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Avon

    AI-generated summary

    Marcie Joan TADMAN · 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

    Marcie Joan Tadman died on 5 December 2017 at Royal United Hospital after admission with pneumonia and parapneumonic effusion. The report describes failures to recognise and manage sepsis, follow hospital procedures and protocols, communicate effectively, conduct proactive reviews, and make appropriate decisions. It also identifies the absence of a paediatric high dependency unit at the hospital as a concern.

    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 second consultant review on the paediatric ward

    Wider context from the report

    “• I heard from the independent expert Dr. Ninis that the only opportunity for Marcie to be picked up with fresh eyes would have been at another ward. I understand that this would be an opportunity for a Consultant to take a step back and review the notes, charts, PEWS and results; examine the patient and to make a plan. In Marcie’s case everyone agreed that all of the information was there in her records but no one carried out this exercise; there was and is no second word round on the paediatric ward at the RUH. ”

    Source location

    Marcie Joan TADMAN · 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

    Share a briefing paper with commissioners detailing staffing, equipment and ward redesign requirements for paediatric critical care.

    Verbatim wording from the response

    “As the Learned Coroner also raised concern about the lack of a permanent paediatric High Dependency Unit (referred to here as Paediatric Critical Care), the Trust has, on 21st May 2019, shared a briefing paper with its commissioners, detailing what would be required to deliver paediatric critical care. This sets out a requirement to do the following:”

    Source location

    2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 1 · response
    Published 9 June 2019

    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

    A second consultant ward round cannot be delivered immediately because it depends on establishing a Paediatric Critical Care Unit.

    Verbatim wording from the response

    “The Trust has identified that an additional consultant evening session (4 hours) would be required each day to enable it to deliver a second ward round which would not only encompass new admissions but any patient about whom a concern had been raised, including patients receiving critical care. This is not a change in practice that the Trust has been able to deliver immediately. The ability to do this is directly linked to the provision of a Paediatric Critical Care Unit and therefore the plans outlined below presented to the commissioners take clear account of a second ward round being integral to this development.”

    Source location

    2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 1 · response
    Published 9 June 2019

    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

    Delivery of the proposed Paediatric Critical Care Unit and twice-daily ward rounds depends on commissioners supporting the plans and funding.

    Verbatim wording from the response

    “If the Trust’s Commissioners are satisfied with the Trust’s proposals, the RUH are aiming to deliver not only twice daily consultant ward rounds, but paediatric high dependency care by Winter 2019. The position of the Commissioners will be set out in their response to the Regulation 28 Report forwarded to them, however, if they”

    Source location

    2019-0118-Response-by-Royal-United-Hospitals-Bath-NHS-Trust
    Page 1 · response
    Published 9 June 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026