Recurring concern

Delays in consultant review of patients

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First reported 24 Sep 2013•Latest report 27 Feb 2026

Definition

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.

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
35

Distinct published reports

Individual concerns
37

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
32

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care7
Care Quality Commission3
Barts Health NHS Trust2
East London NHS Foundation Trust2
Royal College of Obstetricians and Gynaecologists2
Royal College of Paediatrics and Child Health2
St Peter's Hospital2
Tameside General Hospital2
University Hospitals Sussex NHS Foundation Trust2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Betsi Cadwaladr University LHB1
Colchester Hospital1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Suffolk and North Essex NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Michael William Flynn · 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

    Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

    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 or rearrange consultant review after the post operative area

    Wider context from the report

    “6. Mr Flynn was not seen by a consultant after he left the post operative area. A ward round should have taken place the day after his operation but did not take place because the consultant was otherwise engaged. No arrangements were made for it to be rearranged. ”

    Source location

    Michael William Flynn · 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

    Review and revise consultant job plans to support consultant ward-round availability, subject to management approval.

    Verbatim wording from the response

    “With regards to your concerns that a Consultant did not see Mr. Flynn on the day after his operation, the Trauma and Orthopaedic Directorate Managers have advised that a Consultant team job planning session has taken place with the Specialty to discuss the availability of Consultants to undertake ward rounds. The team have agreed to job plans being reviewed and revised and individual Consultant job planning meetings are progressing. I understand the team aim to have completed all job planning meetings including senior management review and approval by mid-April 2019.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 4 · response
    Published 23 May 2019

    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

    Develop a triggered referral process to orthogeriatricians for patients requiring senior review.

    Verbatim wording from the response

    “In addition, I am informed that discussions have taken place with the Directorate of Medicine to implement a triggered referral process to the Orthogeriatricians in cases where patients are identified as requiring a senior level orthogeriatric review. I have gained assurances from the Deputy Directorate Manager for Trauma and Orthopaedics that she is currently working with the Directorate Manager for Medicine to develop the process. The Specialty anticipates that these measures will provide additional support to the clinical teams and patients, ensuring senior medical reviews take place appropriately.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 4 · response
    Published 23 May 2019

    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

    Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.

    Verbatim wording from the response

    “To obtain some assurance in this matter, I understand a review of case notes is scheduled to commence in March 2019 on both the Planned and Emergency Orthopaedic wards to evaluate the medical documentation in relation to daily entries in the medical notes, the grade of doctor reviewing the patient, and whether an orthogeriatric review has taken place where indicated.”

    Source location

    2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
    Page 4 · response
    Published 23 May 2019

    Open published response
  2. Brighton and Hove

    AI-generated summary

    Barry John TUCKER · 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

    The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

    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

    Unavailability of senior urology input during admission

    Wider context from the report

    “(2) The Urology Consultant Surgeon was away during his admission and he had no senior input. ”

    Source location

    Barry John TUCKER · 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

    Assign patients to a consultant who is present or arrange consultant cover during leave.

    Verbatim wording from the response

    “Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018 Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 4 · response
    Published 8 March 2018

    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

    Amend consultant job plans to require daily postoperative rounds.

    Verbatim wording from the response

    “Recommendation | Action | Source of assurance action embedded in practice | Lead | Deadline | Date completed Patients must be assigned to a consultant who is present (to see the patient or cover for the consultant of the week to cover for annual or study leave) | Discussed at Clinical Governance meetings | Observed at safety huddle on ward | Clinical lead | Feb 2018 | 1 Feb 2018 Patients must be reviewed by consultant daily post-operatively. | Job plan to be amended to include daily rounds | Audit of notes in 3 months to ensure daily consultant review has taken place | Clinical lead | Job plan amended Feb 2018 for audit May 2018”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 4 · response
    Published 8 March 2018

    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

    Senior clinical input remained available through an experienced robotic fellow and the urology consultant of the week during the responsible consultant’s leave.

    Verbatim wording from the response

    “(2) The urology consultant was away during his admission and he had no senior input.”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 3 · response
    Published 8 March 2018

    Open published response
  3. Shropshire, Telford and Wrekin

    AI-generated summary

    Jeff David ANTWIS · 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

    Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.

    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 an urgent medical review after suicidal ideation was identified

    Wider context from the report

    “(1) Following an urgent referral by Jeff’s GP to (the then) Shropshire CAMHS on the 10th January 2017 a timely response was made with an initial appointment with a mental health practitioner taking place on the 12th. A further appointment was arranged for the 25th January (an earlier date clashed with an existing medical appointment) and in the meantime Jeff was given a miracle question to complete. (2) Jeff answered the miracle question indicating that he wished to die. He passed it to his mother who immediately contacted the mental health practitioner who in turn referred it and the initial assessment to a consultant psychiatrist for review. The consultant psychiatrist did not consider the matter urgent and arranged for a routine medical review for the 17th March 2017. (3) At the second meeting on the 25th January 2017 Jeff and his mother were informed of the appointment for the 17th March 2017. Jeff’s mother immediately raised concerns and asked for it to be brought forward. She was told she would have to write in and make a complaint. This was a time sensitive situation adding to the problem without resolving it. (4) On the 30th January 2017 Jeff killed himself on the railway line. (5) Independent expert evidence from a child and adolescent consultant psychiatrist indicated that Jeff should have been offered an urgent medical review appointment for the 27th January 2017 (i.e. within 7 days of the internal referral to the consultant psychiatrist) and not, as a routine appointment, the 17th March 2017. It cannot be said that such an earlier appointment would have addressed Jeff’s problems and altered his wish to die but it is possible that earlier intervention may have lifted his spirits and not, according to his mother, ‘wilted’. It undoubtedly would have helped and at least been an earlier step in seeking to help Jeff. (6) Other matters of concern arose from the evidence. The mental health practitioner: a) Was aware of the deliberate self-harm protocol but not its content. b) Carried out a risk assessment on a subjective basis without reference to any known definition e.g. serious or significant. c) Had no mechanism for referring back to the consultant psychiatrist appointment, whether she agreed with the request or not. (7) As stated Jeff had a diagnosis of asperger’s syndrome with autistic spectrum disorder. Concerns were raised to what extent these conditions have may have masked Jeff’s suicidal ideation on presentation and to what extent, if it is the case, they were recognized. (8) From evidence given at the inquest it is clear that the provision of child and adolescent mental health service is in transition, having moved from Shropshire CAMHS to part of South Staffordshire and Shropshire NHS Trust. Certain actions are already being taken and these concerns are raised so that a holistic approach can be taken and fed in to what is already an ongoing wider review. ”

    Source location

    Jeff David ANTWIS · Prevention of Future Deaths report
    Page 1 · 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

    Reserve one weekly appointment in each consultant psychiatrist job plan for urgent assessments.

    Verbatim wording from the response

    “• One assessment appointment each week is ring fenced for urgent assessments in each Consultant Child & Adolescent Psychiatrist job plan to ensure that young people presenting in crisis are provided with urgent psychiatric review (points 2, 4, 5 & 7)”

    Source location

    2017-0392-Response
    Page 3 · response
    Published 15 February 2018

    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

    Establish escalation processes within clinical pathways to obtain urgent psychiatric reviews when concerns arise.

    Verbatim wording from the response

    “• Escalation processes have been agreed within clinical pathways so that urgent psychiatric reviews can be obtained when concerns are raised (points 2, 4, 5 & 7)”

    Source location

    2017-0392-Response
    Page 3 · response
    Published 15 February 2018

    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

    Shropshire Community Health NHS Trust was responsible for investigating care because it provided CAMHS services in Shropshire at the relevant time.

    Verbatim wording from the response

    “As identified in your letter South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not providing CAMHS services within Shropshire at the time of Jeff’s death therefore South Staffordshire and Shropshire Healthcare NHS Foundation Trust were not in a position to have carried out an investigation into the care of Jeff prior to his death. The Serious Incident Investigation presented at the inquest was carried out by Shropshire Community Health NHS Trust who were providing CAMHS services in Shropshire in January 2017.”

    Source location

    2017-0392-Response
    Page 1 · response
    Published 15 February 2018

    Open published response
  4. Inner North London

    AI-generated summary

    Janet WILLIAMS · 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

    Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

    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 maintain timely medical review arrangements

    Wider context from the report

    “3. Ms Williams was not reviewed in accordance with the protocol for a person on a CPA. A medical review with her consultant psychiatrist scheduled for 12 May 2016 was cancelled by her care co-ordinator. The reason given was that the psychiatrist was unwell, though in fact she was not. ”

    Source location

    Janet WILLIAMS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Manchester North

    AI-generated summary

    Ms Edith Robinson · 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

    Ms Edith Robinson was admitted to Accident and Emergency after a fall, with problems identified with her prosthetic hip. Surgery was delayed and, as she deteriorated, action was not taken to rescue her; she died at Royal Oldham Hospital on 20 June 2016. The report identified concerns about weekend consultant review, early warning score calculation and use, record keeping, escalation, communication and other aspects of care.

    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 review of patients over weekends

    Wider context from the report

    “1. Consultant Review over Weekends - During the course of the evidence, I heard that patients such as the deceased are not seen or reviewed by a Consultant over the weekend. I am concerned that this gap in care is putting patients at serious risk. The signs and symptoms of life-threatening illnesses (such as sepsis) are not being diagnosed and/or treated appropriately. Diagnosis and treatment is often time critical and requires significant clinical skill and expertise as signs can be subtle. ”

    Source location

    Ms Edith Robinson · Prevention of Future Deaths report
    Page 1 · 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 the NHS to make seven-day services available in all hospitals.

    Verbatim wording from the response

    “Firstly, on the matter of consultant review over weekends, I can assure you that it is a key commitment of the Government to work with the NHS so that seven day services are available in all hospitals.”

    Source location

    Edith-Robinson-Response
    Page 1 · response
    Published 19 July 2017

    Open published response
  6. Preston and West Lancashire

    AI-generated summary

    Michael John NEWELL · 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

    Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

    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

    Unavailability of consultant ENT input in complex ENT cases

    Wider context from the report

    “(3) there was a worrying lack by the ENT surgeons to realise the complexity of the case due to the ongoing haemorrhage, decompensated liver failure and associated coagulopathy, that there were no base of skull fractures and to select a method of treatment with Rapid Rhino Pack's that in the view of the ENT expert was only appropriate as a first-line measure and not for facial fractures. Firstly, there was no consultant ENT input into Mr Newell's case at any point prior to his death. Secondly, none of the above issues were brought to the attention of the Court in the ENT consultant's statement raising issues within the Trust for improving patient care. ”

    Source location

    Michael John NEWELL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. North Wales (East and Central)

    AI-generated summary

    Christopher Glyn Jones · 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

    Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.

    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

    Infrequent consultant psychiatrist review of recently sectioned and treated inpatients

    Wider context from the report

    “1. Evidence at the inquest indicated that the deceased was discharged from inpatient treatment on the 6th of January 2015 but his Care Treatment Plan was not completed until the end of April 2015 and that this would then only require review within a period of twelve months from that date, as a result it could have been the case that a patient who had recently been sectioned and treated as an inpatient may not then be seen by a consultant psychiatrist for a period in the region of sixteen months. ”

    Source location

    Christopher Glyn Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Black Country

    AI-generated summary

    Tommi-Ray Colin Vigrass · 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

    Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.

    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 consult the on-call consultant before making extubation decisions

    Wider context from the report

    “1. Evidence emerged during the inquest that the Paediatric Doctor in charge recognised that it was a mistake to extubate baby when he did. His words were: “What should have been a straight forward ET change turned into a nightmare”. He also confirmed that he should have consulted the Consultant on call prior to making the decision and earlier use of the CO2 monitor would have made a difference. ”

    Source location

    Tommi-Ray Colin Vigrass · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Surrey

    AI-generated summary

    Rhi anne Anoushka Florence BARTON · 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

    Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric 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 provide timely obstetric consultant supervision after emergency admission

    Wider context from the report

    “1. Rhi anne’s named obstetric consultant was not informed of her emergency admission. Although there was a consultant obstetrician on the ward on the 11th February there was no request for Rhi anne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhi anne from the time of admission until shortly before her surgery; approximately 43 hours after admission. ”

    Source location

    Rhi anne Anoushka Florence BARTON · 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

    Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.

    Verbatim wording from the response

    “We have actioned a change in Consultant working practices to facilitate timely review of patients on Joan Booker Ward. The default planning is that Consultants will review patients under their care every working day; where other commitments or absences preclude this, and at weekends, the labour ward Consultant will review the patients. This pattern of working has been in place since March 2015. I have included as Appendix 1, the details of this working pattern.”

    Source location

    2016-0213-Response-by-Ashford-and-St-Peters-Hospital-NHS-Trust
    Page 1 · response
    Published 1 June 2016

    Open published response
  10. Mid Kent and Medway

    AI-generated summary

    Jonathan Lewis Fry · 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

    Jonathan Lewis Fry was admitted after an unwitnessed fall and was diagnosed with an L1 compression fracture. He later became increasingly unwell and was found unresponsive on 20 April 2015; the post-mortem cause of death was recorded as pulmonary embolism due to deep venous thrombosis. The principal concerns were the absence of senior Consultant review, inadequate follow-up of tests and results, and inconsistent or incomplete medical records.

    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 senior Consultant review

    Wider context from the report

    “1) There was no Senior review by a Consultant from admission to the time of his death and was no locum cover ”

    Source location

    Jonathan Lewis Fry · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026