Recurring concern
Unreliable contact arrangements for urgent clinical advice
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Request correctionFirst reported 23 Oct 2014•Latest report 26 May 2026
What this concern includes
Includes failures of dedicated arrangements for contacting or obtaining urgent advice from an on-call doctor or specialist clinical service, including unavailable contact routes, unresponsive clinicians and failures to complete the required contact for urgent review.
Not included
- Excludes ordinary delays in clinical treatment, referral or specialist attendance where the process for obtaining urgent clinical advice was not deficient.
- Excludes generic communication, staffing or telephone-system deficiencies unless they directly prevent clinicians from obtaining urgent clinical advice.
- Excludes non-clinical on-call, emergency-control-room or administrative contact processes.
- Excludes failures occurring after urgent clinical advice has been successfully obtained, including the subsequent quality of the advice or treatment decision.
- Reports
- 8
- Individual concerns
- 8
- Date range
- 2014–2026
- Stated actions
- 6
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Delays in contacting 999 and the on-call doctor during cardiac arrests
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Action
Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.
Stated by SPFT -
Action
Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.
Stated by SPFT
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.
Stated by SPFT
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Concerns raised1
Failure to provide timely access to the Duty Doctor for deteriorating patients
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Action
Implement a dedicated NHS wireless network enabling junior doctors’ smartphones to use Wi-Fi calling at identified Kingsmill locations, and distribute user guidance.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure to contact the respiratory on-call consultant on repeat presentation
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 concernsEach 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.1
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Action
Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
A further respiratory referral was not considered necessary because the patient had the same symptoms only two days earlier.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
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Concerns raised1
Failure to obtain and follow up further haematology advice when INR remains above target
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Position
Existing 24-hour haematology support, anticoagulation guidance and ward-team responsibilities provide arrangements for INR management and follow-up.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Unavailability of a daily clinician for practice access and urgent clinical advice
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to contact the on-call doctor
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 concernsEach 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.1
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Action
Complete a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.
Stated by the Dudley Group NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The investigation found no nerve centre system failure; the failure to contact a doctor resulted from human error entering incorrect patient details.
Stated by the Dudley Group NHS Foundation Trust
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Concerns raised1
Unclear designation of the doctor to contact after an acute NEWS change
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.1
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Action
Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure of the Haematology Department to remain contactable by attending doctors
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026