Recurring concern

Unsafe on-call consultant rota arrangements

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First reported 5 Mar 2015•Latest report 14 Sep 2018

Definition

What this concern includes

Includes failures of hospital consultant on-call rota arrangements, including maintaining and accessing current rota information, identifying the correct on-call consultant, managing amendments through a reliable central process, and scheduling duties with adequate post-duty rest where these controls support safe consultant availability.

Not included

  • Excludes delays in consultant review or attendance where the on-call rota arrangements are not themselves deficient.
  • Excludes general staffing shortages, workforce fatigue or rota problems involving non-consultant staff unless they are explicitly part of consultant on-call rota arrangements.
  • Excludes ordinary appointment scheduling and non-clinical duty rotas.
  • Excludes broader clinical governance, supervision or handover failures that do not concern the consultant on-call rota system.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2018

First to latest report issue date

Stated actions
4

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.

Avon and Wiltshire Mental Health Partnership NHS Trust1
Royal Stoke University Hospital1
University Hospitals of Leicester NHS 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. Wiltshire and Swindon

    AI-generated summary

    Terence Andrew Bennett · 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

    Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.

    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

    On-call rota failing to provide rest and recuperation after 12-hour night duties

    Wider context from the report

    “10. The on-call rota for duty consultants meant that consultant psychiatrists on occasions faced a full day of clinical work immediately following the completion of a 12 hour night time duty, without any period of rest and recuperation. ”

    Source location

    Terence Andrew Bennett · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Nadim Muzzfar BUTT · 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

    Nadim Muzzfar BUTT died on 5 September 2014 after complications following laparoscopic gastric bypass surgery, including small bowel obstruction, systemic inflammatory response syndrome and multi-organ failure. The report raised concerns that the hospital review was not escalated to a serious untoward incident or root cause analysis, and that no consultant-led out-of-hours on-call rota was in place for postoperative 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

    Lack of a consultant-led out-of-hours on-call rota for postoperative patients

    Wider context from the report

    “2. Despite the recognition that a consultant-led out of hours on-call rota is required for patients having undergone surgery, no such rota is yet in place. ”

    Source location

    Nadim Muzzfar BUTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Leicester City and South Leicestershire

    AI-generated summary

    Michael Andrew Pollard · 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 Andrew Pollard, aged 14, collapsed at home on 23 June 2014 and was admitted with an upper gastrointestinal bleed. He became unresponsive before an endoscopy was arranged and died from massive haemorrhage several hours later on 24 June 2014. Concerns included delays in escalation to senior colleagues, lack of early intensive care involvement, inadequate resuscitation with blood products, and an out-of-date on-call rota that delayed contacting the appropriate consultant.

    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 an up-to-date and accessible on-call rota

    Wider context from the report

    “During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future. In my opinion the following matters need to be considered (1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it (2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota (3) ”

    Source location

    Michael Andrew Pollard · Prevention of Future Deaths report
    Page 1 · 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 restrict on-call rota amendments to a single central point

    Wider context from the report

    “During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future. In my opinion the following matters need to be considered (1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it (2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota (3) ”

    Source location

    Michael Andrew Pollard · 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

    Review the on-call rota system through the Switchboard Management Team.

    Verbatim wording from the response

    “As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported to our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and I can confirm that this will occur here.”

    Source location

    2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 2 · response
    Published 4 March 2015

    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

    Remind all doctors of their responsibility to notify Switchboard about on-call rota amendments.

    Verbatim wording from the response

    “As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.”

    Source location

    2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 2 · response
    Published 4 March 2015

    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

    Remind Switchboard staff of their responsibility to keep the on-call rota updated.

    Verbatim wording from the response

    “As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.”

    Source location

    2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 2 · response
    Published 4 March 2015

    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

    Procure a Trust-wide web-based system to manage on-call rotas.

    Verbatim wording from the response

    “The Trust is in the process of procuring a trust-wide web-based system to manage our on-call rotas. Our Chief Medical Information Officer expects to have this system available for use throughout the Trust by the end of this calendar year. Once adopted this system should strengthen and improve our processes with information being uploaded in real-time and visible to clinicians.”

    Source location

    2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 2 · response
    Published 4 March 2015

    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 central amendment point and clinician access process already address the need for accurate, accessible on-call rota information.

    Verbatim wording from the response

    “Clinicians who need to access the on-call information can do so via Switchboard.”

    Source location

    2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
    Page 2 · response
    Published 4 March 2015

    Open published response
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Data last updated 7 September 2026