Recurring concern

Unreliable out-of-hours access to hospital theatres

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First reported 23 Aug 2013•Latest report 26 Nov 2013

Definition

What this concern includes

Includes failures of out-of-hours hospital-theatre access or capacity that delay or threaten urgent procedures, emergency surgery, or retrieval of additional instrumentation, including access arrangements, theatre availability, competing emergency demand and contingency provision.

Not included

  • Excludes ordinary daytime theatre access or elective theatre scheduling where out-of-hours availability is not the identified concern.
  • Excludes delays in procedures caused solely by surgical decision-making, staffing competence or postoperative care when theatre access or capacity is not deficient.
  • Excludes access to non-theatre clinical areas, diagnostic services or equipment unless the assertion specifically concerns obtaining it through out-of-hours theatre access.
  • Excludes generic hospital capacity or emergency-care delays without a direct out-of-hours theatre access or capacity connection.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2013

First to latest report issue date

Stated actions
3

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.

NHS Lewisham Clinical Commissioning Group1
NHS South East London Integrated Care Board1
Pennine Acute Hospitals NHS Trust1
University Hospital Lewisham1

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 North

    AI-generated summary

    Barry James LEWIS · 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

    Barry James Lewis suffered an anaphylactic reaction of unknown origin and developed severe airway swelling and difficulty speaking. Despite emergency treatment, attempts to secure his airway were difficult, he suffered respiratory and cardiac arrest, and he died after 50 minutes of resuscitation. The substantive concerns related to the availability and suitability of emergency airway instruments, theatre access, night staffing, and out-of-hours ENT cover across multiple sites.

    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

    Limited out-of-hours accessibility of theatres to obtain additional instrumentation

    Wider context from the report

    “4) The accessibility of theatres in order to obtain additional instrumentation when needed, out of hours. ”

    Source location

    Barry James LEWIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner South London

    AI-generated summary

    Luna Lesko · 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 Luna Lesko died after being found collapsed with no respirations following an airway occlusion, inadequate required observations and a prolonged period of hypoxia, despite resuscitation and intensive care. The report raised concerns about delays in cardiotocograph monitoring and delivery by caesarean section, including insufficient out-of-hours theatre capacity and a potential risk to future babies.

    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

    Insufficient out-of-hours obstetric theatre capacity

    Wider context from the report

    “(2) LSCS was required for the baby, due to lack of progression despite augmentation, adverse position and prolonged rupture of membranes with meconium. The decision was taken at 20.00 hours, but delivery was not possible until 21.40 hours, as theatres were busy. This delay of 1 hour 40 minutes for a category 2 section was 40 minutes outside the Trust’s own guidelines. (3) The consultant obstetrician reported that this delay, which occurred out of hours, in a unit with over 4000 births per year was unacceptable. It worsens the potential impact, carrying a higher risk of brain damage or death of babies, if there were several emergencies at one time. Staff were reluctant to use the second out of hours (non obstetric) theatre as they cannot then respond to a category 1 emergency. My expert obstetric witness, ████████ of Kings College Hospital, gave an opinion that the out of hours theatre access created a real risk of preventable death, especially with the increasing rate of performing LSCS. He advised me that I should be concerned and bring the matter to the attention of the Trust. (4) Whilst the Head of Midwifery reported management changes and compliance with CNST assessment, she did not provide assurance that the theatre capacity had been increased out of hours. Furthermore it was reported that the Trust is shortly to be disbanded and a new Trust is being formed by merger with another. This may lead to service configuration changes. She reported that the future obstetric services were under review. (5) I concluded that a real risk existed that I should report to the Trust and the commissioning body, to ensure that it was fully appreciated and given appropriate priority in the service reconfiguration planning. ”

    Source location

    Luna Lesko · 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

    Convert the labour-ward obstetric theatre to a 24-hour emergency obstetric theatre by the end of March 2014.

    Verbatim wording from the response

    “The College recommends that an operating theatre dedicated for obstetrics should be close to the labour ward, or preferably within it. Lewisham’s obstetricians have requested that the obstetric theatre located on labour ward be changed from being primarily used for elective Caesarean sections to being the emergency obstetric theatre 24 hours a day. We have reviewed whether there are any reasons why this cannot be the case and propose to implement the change by the end of March 2014. As mentioned above, the obstetric team already has access to a second theatre out of hours and at weekends. In addition, we are assessing whether access to a second theatre can also be provided during normal working hours whilst at the same time minimising the impact on the Trust’s other surgical activity and clinical priorities.”

    Source location

    2013-0214-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 23 August 2013

    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 business case for additional operating department practitioner and nursing staff, then submit it for executive review and CCG discussion.

    Verbatim wording from the response

    “An additional theatre team would be required to ensure that two emergency theatres were guaranteed for the maternity unit. This would include an Operating Department Practitioner and nursing staff. The Women’s and Surgery Clinical Divisions are developing a business case for this additional resource, which will be reviewed at Executive Director level within the Trust and discussed with Lewisham CCG. The timescale for this is 3 to 6 months.”

    Source location

    2013-0214-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 23 August 2013

    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

    Increase elective Caesarean section lists in main theatres from weekly to three times weekly by the end of January 2014, with additional staffing planned.

    Verbatim wording from the response

    “The maternity unit currently has an elective Caesarean section list once a week during normal working hours, which is scheduled in main theatres. Our plan is to increase this to three times a week within the main theatre unit by the end of January 2014, as this would release the obstetric unit theatre for emergencies. Theatre allocation has already been identified and planning of additional staffing resource is underway. The additional elective lists in main theatres would also enable midwives and on call doctors to be freed up to focus on labouring women. At present, elective procedures sometimes have to be cancelled to make way for emergency cases; the former may then become urgent or emergency situations requiring out of hours theatre time.”

    Source location

    2013-0214-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 23 August 2013

    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 out-of-hours access to a second theatre is considered sufficient while additional normal-hours capacity is assessed.

    Verbatim wording from the response

    “The College recommends that an operating theatre dedicated for obstetrics should be close to the labour ward, or preferably within it. Lewisham’s obstetricians have requested that the obstetric theatre located on labour ward be changed from being primarily used for elective Caesarean sections to being the emergency obstetric theatre 24 hours a day. We have reviewed whether there are any reasons why this cannot be the case and propose to implement the change by the end of March 2014. As mentioned above, the obstetric team already has access to a second theatre out of hours and at weekends. In addition, we are assessing whether access to a second theatre can also be provided during normal working hours whilst at the same time minimising the impact on the Trust’s other surgical activity and clinical priorities.”

    Source location

    2013-0214-Response-by-Lewisham-Greenwich-NHS-Trust
    Page 2 · response
    Published 23 August 2013

    Open published response
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Data last updated 7 September 2026