Recurring concern

Unreliable hospital bleep systems for urgent clinical communication

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First reported 19 Sep 2020•Latest report 1 Mar 2024

Definition

What this concern includes

Includes failures of hospital bleep systems used for urgent clinical communication or emergency alerts, including unavailable devices, inability to transmit sufficient information electronically, unreliable operation and failure of the system to support prompt alerting of the responsible clinical team.

Not included

Excludes generic communication, handover or task-prioritisation failures where no hospital bleep-system deficiency is identified.
Excludes failures of ambulance, police, fire or other emergency-service communication systems unless the assertion specifically concerns a hospital bleep system.
Excludes failures to respond to a correctly received bleep where the bleep system itself operated reliably.
Excludes generic staff training or workflow deficiencies where the hospital bleep system is not the deficient control.

Reports: 3
Individual concerns: 3
Date range: 2020–2024
Stated actions: 5

Reports 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.

Betsi Cadwaladr University LHB1

Mid and South Essex NHS Foundation Trust1

The Queen Elizabeth Hospital, King's Lynn1

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 Mar2024
North Wales (East and Central)
Concerns raised1
1. Failure of the bleep system to convey information electronically
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.
  Stated by Betsi Cadwaladr University LHBStated planned
3. Action
  Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.
  Stated by Betsi Cadwaladr University LHBStated in progress
1. Action
  Decide the specific future communication solution using the results of technical testing with frontline clinicians.
  Stated by Betsi Cadwaladr University LHBStated planned
AI-generated summary

Jennifer Ann Trigger · 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

Jennifer Ann Trigger was admitted to Wrexham Maelor Hospital on 29 January 2020 after suffering an acute stroke and was prescribed beriplex, a time-critical treatment, which was not administered until the following morning. The report identified miscommunication and limitations in the bleep system as contributing to delays in prioritising and administering the treatment, followed by deterioration in her condition and her death on 31 January 2020.

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 of the bleep system to convey information electronically
Wider context from the report
“There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition. Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors. ”
Source location
Jennifer Ann Trigger · 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
Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.

Verbatim wording from the response
“The Health Board has been working on a paging system replacement and upgrade project for 12 months.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 6 March 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
Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.

Verbatim wording from the response
“The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 1 · response
Published 6 March 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
Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.

Verbatim wording from the response
“The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 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
Decide the specific future communication solution using the results of technical testing with frontline clinicians.

Verbatim wording from the response
“The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 March 2024
Open published response
25 Nov2022
Norfolk
Concerns raised1
1. Failure to use the emergency bleep system to alert the paediatric team
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The Trust found no measurable efficiency difference between notifying paediatric staff in person and using the emergency bleep system.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustDisputes the concern
1. Position
  Existing trained staff, emergency-call arrangements and resuscitation cover were considered to mitigate risk, so no system change was required.
  Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Bonnie Rose WEBSTER · 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

Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

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 use the emergency bleep system to alert the paediatric team
Wider context from the report
“3. Evidence was heard that staff alerted the paediatric team on foot, rather than using the emergency "bleep" system. ”
Source location
Bonnie Rose WEBSTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 found no measurable efficiency difference between notifying paediatric staff in person and using the emergency bleep system.

Verbatim wording from the response
“Due to the theatre being immediately adjacent to NICU there was no measurable difference in efficiency between using the "bleep" system and notifying the paediatric team in person. All clinical staff are trained on using the "bleep" system and at any time there will be multiple staff members in theatre able to make this call, rather than this responsibility resting on one”

Source location
Response from The Queen Elizabeth Hospital King's Lynn
Page 2 · response
Published 25 November 2022
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
Existing trained staff, emergency-call arrangements and resuscitation cover were considered to mitigate risk, so no system change was required.

Verbatim wording from the response
“We recognise that for the runner to have been unable to make the call there is potential additional clinical risk, but we consider that the risk is fully mitigated; firstly, by the fact that in default there are other staff in theatre other than the runner who can do call the emergency number. Secondly, on all occasions where a non-elective caesarean section is being performed, staff trained in resuscitation, namely midwives and junior paediatric staff, are present before birth takes place. We therefore do not think that any change to our system is required with reference to additional appropriately qualified staff being present at birth or securing the attendance of the Consultant Paediatrician.”

Source location
Response from The Queen Elizabeth Hospital King's Lynn
Page 3 · response
Published 25 November 2022
Open published response
19 Sep2020
Essex
Concerns raised1
1. Unavailability of a bleep in the neonatal unit
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide the neonatal unit senior nurse with a 24-hour bleep linked to the Code Blue emergency call.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
AI-generated summary

Frederick Joseph Terry · 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

Baby Frederick Joseph Terry was delivered by caesarean section after a failed forceps attempt on 16 November 2019, and death was confirmed after 40 minutes of resuscitation attempts. The stated cause of death was hypovolaemic shock due to skull fracture, scalp laceration and haemorrhage arising from birth trauma. Concerns included risk assessment and forceps delivery, excessive force and traction, staff training and levels, communication, record keeping, resuscitation equipment and procedures, and neonatal unit 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
Unavailability of a bleep in the neonatal unit
Wider context from the report
“The need for a bleep in the neonatal unit ”
Source location
Frederick Joseph Terry · 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 the neonatal unit senior nurse with a 24-hour bleep linked to the Code Blue emergency call.

Verbatim wording from the response
“Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis (whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is summoned as required using the ‘Code Blue’ emergency call.”

Source location
2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
Page 2 · response
Published 16 November 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the bleep system to convey information electronically

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Failure to use the emergency bleep system to alert the paediatric team

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Unavailability of a bleep in the neonatal unit

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 4

Respondent positions 2

Actions described in response 1