Recurring concern

Failure to provide timely medical review of admitted patients

First to latest report 4 Oct 2013 — 17 Jun 2025

Reports that mention this concern
24
Times this concern has been raised
27
Stated actions linked to this concern
35

What this concern includes

Includes failures of the inpatient medical-review process involving absent, delayed or insufficiently timely review of admitted or transferred patients, including review prompted by clinical observations, deterioration, presenting symptoms or a request from ward staff.

What is not included
  • Excludes delays limited to consultant review where the broader medical-review process is not deficient.
  • Excludes nursing observations, monitoring or escalation failures when no failure to provide medical review is identified.
  • Excludes generic staffing, documentation, communication or handover deficiencies unless they directly result in absent or delayed medical review of an admitted patient.
  • Excludes outpatient, community or non-inpatient clinical reviews.

Reports and published responses 24 reports

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

  1. Surrey

    AI-generated summary

    Maria De Oliveria Alva LOPES · 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

    Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.

    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 ward rounds in weekend urology on-call arrangements

    Wider context from the report

    “1. The consultant urologist’s on call arrangements covering three hospitals at the weekend has no provision for consultant ward rounds, in contravention of suggested national guidelines ”

    Source location

    Maria De Oliveria Alva LOPES · 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

    Delays in urology review of emergency admissions

    Wider context from the report

    “4. The review of emergency admissions by urology (not on day of admission, once daily) ”

    Source location

    Maria De Oliveria Alva LOPES · 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 weekend urology review and supervision through consultant ward rounds, registrar emergency assessments, case discussion and consultant availability.

    Verbatim wording from the response

    “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 2014

    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

    Review the three-hospital urology on-call services and develop an action plan toward seven-day compliance.

    Verbatim wording from the response

    “This has set out standards which would mean that all emergency in patients would be assessed by a suitable consultant within six hours, (during periods of consultant presence on an acute ward) and, at other times, must have a thorough clinical assessment by a suitable consultant within 14 hours of arrival in hospital. Implementation of this guidance is over the next three years, with a submission of action plans in 2014/15, implementation of the greatest impact changes in 2015/16 and compliance by 2016/17. These standards represent a paradigm shift from the usual on-call arrangements concerning urology in the majority of hospitals in this country. The three trusts will need to undertake a review of the on-call services to develop an action plan towards becoming compliant with 7-day working.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 2014

    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

    No specific national urology on-call guidelines existed; the cited recommendations were recent and not yet fully implemented.

    Verbatim wording from the response

    “There are no current suggested national guidelines concerning the provision of consultant ward rounds but we believe this is a reference to the guidelines produced by Sir Bruce Keogh in a paper presented to NHS England in December 2013, outlining seven days a week service.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 2014

    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 weekend arrangements provide registrar and consultant review of urology emergency admissions and inpatients.

    Verbatim wording from the response

    “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 2014

    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 arrangements provide safe, supervised out-of-hours trainee practice through registrar discussions and consultant advice or review when required.

    Verbatim wording from the response

    “2. A general lack of knowledge or implementation of published ‘on-call’ national guidelines As mentioned above, there are no specific on-call guidelines produced nationally for urology and the Keogh recommendations were published within the last year. These have therefore come into force subsequent to Mrs Lopez's tragic death and it is intended that consultants from all three hospitals meet to discuss future arrangements for on-call. The current on-call arrangements at Frimley Park Hospital have operated safely for over ten years and, by discussing cases with the registrar on Saturday and reviewing collaborative decisions made by the registrars the next day, we are able to provide supervision of the registrars. In addition, the on-call consultant for all three hospitals is able to review patients, if requested.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 11 July 2014

    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

    Consultant-delivered emergency services with regular inpatient ward rounds require additional consultant appointments before compliance can be achieved.

    Verbatim wording from the response

    “3. The overall supervision of out-of-hours urology trainees within the system The overall supervision of out-of-hours' urology trainees within the current system is specific to the arrangements within each Trust. Trainees have access to consultant advice and review, if necessary, 24/7 during the on-call weekend. Provision of consultant-delivered emergency service with regular in-patient ward rounds will require additional consultant appointments to allow trusts to become compliant with Keogh. There is wide variety of provision of urology cover across the country, with approximately 50% of urology departments dependent on general surgical middle grade support. We are fortunate to have urology middle grade support for our emergencies. It is recognised by BAUS that this is an issue that will need to be addressed in the next couple of years.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 11 July 2014

    Open published response

  2. Inner South London

    AI-generated summary

    Sadik Miah · 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

    Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.

    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 physician input into management of in-patients with physical health problems

    Wider context from the report

    “(1) ████████ said that consultant psychiatrists caring for in-patients with physical health problems did not have the benefit of a fellow consultant physician visiting, examining and advising on management, as would occur in a DGH. This did create a risk of other deaths occurring and should be a concern for the coroner. ”

    Source location

    Sadik Miah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Berkshire

    AI-generated summary

    Edna Elsie Mary Eden · 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

    Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic 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

    Delays in medical review of admitted patients

    Wider context from the report

    “(6) An elderly patient who was admitted with a covering letter describing recent chest pain was not seen by a Doctor for a total of fourteen and a half hours. ”

    Source location

    Edna Elsie Mary Eden · 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

    Delays in medical review of admitted patients

    Wider context from the report

    “(1) Mrs Eden was admitted having been prescribed antibiotics by her GP. She was not provided with further antibiotic cover pending being seen by a Doctor and that was unduly delayed meaning that she went fourteen and a half hours without her prescribed medication. ”

    Source location

    Edna Elsie Mary Eden · 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

    Introduce a hospital referral procedure covering Emergency Department referrals.

    Verbatim wording from the response

    “All referrals to the Hospital pass through the Emergency Department. On 14 January 2014 the Trust introduced a new Procedure for dealing with referrals to the hospital. Although some aspects of this new procedure are underway the electronic section is expected to go live in six weeks’ time. The electronic system will ensure that instead of using the bleep system to notify inpatient teams that there is a patient in the Emergency Department or that there is a GP referred patient who needs to be reviewed a message will be sent via Smartphone. The Specialist Registrar receives an e-mail alert and then allocates the job within the team. On receiving the e-mail it will be the inpatient team’s goal to see the patient within one hour of referral thereby ensuring no delays.”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    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

    Implement electronic Smartphone referral notifications with Specialist Registrar allocation and a one-hour inpatient-team review goal.

    Verbatim wording from the response

    “All referrals to the Hospital pass through the Emergency Department. On 14 January 2014 the Trust introduced a new Procedure for dealing with referrals to the hospital. Although some aspects of this new procedure are underway the electronic section is expected to go live in six weeks’ time. The electronic system will ensure that instead of using the bleep system to notify inpatient teams that there is a patient in the Emergency Department or that there is a GP referred patient who needs to be reviewed a message will be sent via Smartphone. The Specialist Registrar receives an e-mail alert and then allocates the job within the team. On receiving the e-mail it will be the inpatient team’s goal to see the patient within one hour of referral thereby ensuring no delays.”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    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 a 24-hour Central Hub with patient tracking, referral and bleep management, workload oversight, handover, task allocation, escalation and senior-manager staffing.

    Verbatim wording from the response

    “The Trust has plans to introduce a 24 hours a day Central Hub system and the timescales for actions are stated in the enclosed action plan. It is envisaged the Hub will be located at Wexham Park Hospital and be equipped with IT systems and run by senior managers who will be responsible for ensuring the following:”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response

  4. Cornwall

    AI-generated summary

    Jean James · 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

    Jean James was an 85-year-old woman who developed stomach pain on 5 November 2012, was admitted to hospital with suspected appendicitis at approximately 11:00 on 6 November, and was not seen by a doctor until 17:00. She was later diagnosed with a perforated appendix, underwent surgery, and died in hospital on 19 November 2012. The principal concern was that patients admitted via their GP had no defined timeframe for medical review, unlike patients admitted through the Emergency Department, and that records of review times were not kept.

    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 time threshold for doctor review and assessment of GP-referred hospital admissions

    Wider context from the report

    “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them. Furthermore, I was told that records in this regard are not kept. On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome. I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department. I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed. It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department. ”

    Source location

    Jean James · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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