Recurring concern

Unreliable hospital theatre booking and availability coordination

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First reported 18 Oct 2013•Latest report 28 Jan 2015

Definition

What this concern includes

Includes failures in hospital-theatre booking and availability coordination, including communicating theatre availability to treating teams, incorporating appropriate surgical input into booking and prioritisation, allocating available theatre capacity and coordinating follow-up arrangements when patients are awaiting surgery.

Not included

  • Excludes delays caused solely by insufficient theatre capacity or out-of-hours theatre availability where the booking and availability-coordination process is not itself deficient.
  • Excludes failures in surgical assessment, referral, pre-operative preparation or treatment after theatre access has been reliably arranged.
  • Excludes generic hospital communication, staffing or management deficiencies unless they directly impair theatre booking, prioritisation or notification.
  • Excludes operating-theatre equipment, anaesthesia and intra-operative safety failures unrelated to booking or availability coordination.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2015

First to latest report issue date

Stated actions
0

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.

Queen's Hospital, Romford1
Stepping Hill Hospital1

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. London (East)

    AI-generated summary

    Iana-Liza Chervonenko · 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

    Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became available.

    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

    Absence of a system for proactively notifying the treating team when theatre becomes available

    Wider context from the report

    “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following: • A delay in obtaining a medical review to the concerning CTG trace. • A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace. • Incorrect documentation in relation to the grading of the caesarean section. • Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient. • The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients. 2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40. The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40. Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40. I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation. I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest. ”

    Source location

    Iana-Liza Chervonenko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Jennifer Elsie RUSHWORTH · 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 circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.

    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 include surgeons’ input in theatre booking

    Wider context from the report

    “Secondly the surgeon indicated that the booking of theatres and follow-up therefrom is dealt with by the management and not from any input from the surgeons themselves. ████████ indicated that it was for this reason that there was a delay in booking this lady in to surgery and that delay may have had a bearing on her wellbeing at the time of surgery but more particularly during the recovery period. Again I would have thought that an input from the surgeons would have been the prime consideration that bed managers should be looking at when booking theatres, etc. ”

    Source location

    Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026