First reported 29 Sep 2015•Latest report 30 Aug 2024
Definition
What this concern includes
Includes failures of the on-call consultant attendance arrangement, including unavailability, delayed attendance, or failure to ensure attendance when requested, where the report links the failure to required clinical care.
Not included
Excludes generic shortages or staffing concerns that are not specifically tied to on-call consultant attendance.
Excludes failures of consultant supervision, advice or review where attendance is not part of the reported unsafe condition.
Excludes attendance by non-consultant staff, specialist teams or emergency services unless the report explicitly concerns the on-call consultant attendance arrangement.
Excludes individual clinical decisions made after an available consultant has attended or been contacted.
Reports
7
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2015–2024
First to latest report issue date
Stated actions
7
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 England3
Department of Health and Social Care2
British Association of Perinatal Medicine1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
General Medical Council1
Greater Manchester Combined Authority1
Maidstone and Tunbridge Wells NHS Trust1
Milton Keynes University Hospital1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Royal College of Paediatrics and Child Health1
Sheffield Teaching Hospitals NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1
NHS trust4
Executive non-departmental public body3
Health professional body2
Ministerial department2
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Mayoral policing body1
Professional body1
Type not available1
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.
West Sussex, Brighton and Hove
Concerns raised1
Variability in on-call Neonatology Consultant attendance times
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Explore options for establishing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2024.
Action
Approach the Integrated Care Board about externally reviewing current arrangements and options to strengthen Neonatal Consultant on-call provision for the Princess Royal Hospital service.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 September 2024.
Action
Recommend against simultaneous out-of-hours cover of geographically separate neonatal sites and concurrent Tier 2 and Tier 3 cover by one consultant.
Stated by British Association of Perinatal MedicineStated completedThe respondent said that this action was complete when they made their response on 2 September 2024.
Action
Publish recommendations requiring immediate consultant availability, attendance within 30 minutes, and robustly job-planned and risk-assessed local coverage arrangements.
Stated by British Association of Perinatal MedicineStated completedThe respondent said that this action was complete when they made their response on 2 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Outcome reviews found no evidence that the current Neonatal Consultant on-call arrangements at Princess Royal Hospital are unsafe or contribute to neonatal deaths.
Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Trust cannot currently provide a separate Princess Royal Hospital rota because Consultant, workforce and financial resources are unavailable.
Stated by University Hospitals Sussex NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Trust is asking the Integrated Care Board to externally review current arrangements and options for strengthening Neonatal Consultant on-call provision.
Stated by University Hospitals Sussex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS Trusts determine their own out-of-hours neonatal consultant response-time policies under consultants’ terms and conditions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
BAPM guidance contains no recommendation specifying the time consultants must be on site.
Stated by British Association of Perinatal MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
BAPM is advisory rather than executive and therefore cannot direct trusts' local implementation processes.
Stated by British Association of Perinatal MedicineOutside remitThe respondent said that this matter was outside its role or authority.
Position
Individual trusts are responsible for implementing local processes in line with national guidelines.
Stated by British Association of Perinatal MedicineRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Reliance on consultants who may be non-resident on call during neonatal resuscitation
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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mandatory non-invasive airway skills, readiness assessment, consultant support and current Newborn Life Support status provide safe preparation for neonatal resuscitation.
Stated by Royal College of Paediatrics and Child HealthExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North East Kent
Concerns raised1
Insufficient consultant availability for night-time emergencies
This report raised 19 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 A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The CQC is responsible for deciding and providing further detail on regulatory action concerning the Trust’s maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised1
Unavailability of the on-call consultant for prompt attendance
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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
On-call doctors must be able to attend within 30 minutes and consultants living farther away must arrange suitable local accommodation while on call.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Mid Kent and Medway
Concerns raised1
Unavailability of a surgical consultant on call from Maidstone during the working week
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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A consultant general surgeon is always on call and accessible, although weekday cover is predominantly based at Tunbridge Wells.
Stated by Maidstone and Tunbridge Wells NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
Concerns raised1
Failure to ensure consultant attendance when requested
This report raised 5 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Embed a revised SBAR handover communication tool in practice.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Action
Recirculate the written escalation policy to all staff.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.
Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The consultant attended within 14 minutes, which was considered appropriate for the case concerned.
Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.
Stated by Milton Keynes University Hospital NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of the on-call consultant attendance arrangement, including unavailability, delayed attendance, or failure to ensure attendance when requested, where the report links the failure to required clinical care.
