Recurring concern

Unreliable contact arrangements for urgent clinical advice

First to latest report 23 Oct 2014 — 26 May 2026

Reports that mention this concern
8
Times this concern has been raised
8
Stated actions linked to this concern
6

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.

What is 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 and published responses 8 reports

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

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Kristian Edward Allen · 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

    Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

    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 contacting 999 and the on-call doctor during cardiac arrests

    Wider context from the report

    “I am also concerned that staff are not properly able to deal with cardiac arrests in acute mental health wards. In Kristian’s inquest, evidence was heard that the response to Kristian’s arrest was chaotic and disorganised. Nobody appeared to be in charge, staff were unable to do CPR properly, the 999 call was of a poor standard, there were considerable delays in contacting 999 and the on call doctor and the staff did not have Naloxone training. I had the same issues in an Inquest I did nine months ago in the exact same ward, indeed in the neighbouring room. The fact that the same set of facts have repeated themselves in Kristian’s case leads me to a very real concern that future deaths will happen if action is not taken. ”

    Source location

    Kristian Edward Allen · 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

    Deliver regular unannounced emergency simulation training to strengthen staff confidence and response to cardiac arrest and opioid overdose.

    Verbatim wording from the response

    “Response to cardiac arrest I appreciate your concern in relation to staff not being properly able to deal with cardiac arrests. You will have heard how this was recognised within the Trust's PSII and the need to strengthen preparedness and response to medical emergencies, including opioid overdose, resulted in recommended action. The identified action was the need to increase staff confidence in administering Immediate Life Support (ILS). I am informed that the Inquest heard of the impact upon staff of conducting ILS and how their confidence can be impacted by the rarity of having to conduct ILS. I confirm, as you heard, that as a direct action from the PSII into Kristian's death the Trust introduced regular simulation training ie: unannounced emergency simulations to which staff then have to respond.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 22 June 2026

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    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

    Update the Resus policy to require monthly clinical and non-clinical emergency simulations across inpatient hospitals.

    Verbatim wording from the response

    “As you also heard in evidence the Trust's Resus policy has been updated to formalise the inclusion of simulation as standard in both clinical and non-clinical areas to enhance and embed medical emergency and cardiac arrest training, thereby ensuring staff remain competent and confident with emergency processes and procedures. The policy stipulates that simulations will be completed monthly throughout SPFT in inpatient hospitals. As ████████ informed you, the most recent simulation on Kristian's ward took place on 20th May, involving 8 staff and simulated a scenario of an opioid overdose leading to cardiac arrest. I am informed that feedback from the ILS team was that the ward-team's response was well led.”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 3 · response
    Published 22 June 2026

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    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 Trust actions embedded in policy, training, governance and ward-level processes are considered sufficient; no further new actions are needed.

    Verbatim wording from the response

    “In summary, given the comprehensive range of actions already taken by the Trust there are no further new actions that I consider the Trust needs to take. That said, as I recognised above, all improvement requires sustained, committed focus. So, whilst I can already say that the actions described above are now embedded within policy, training, governance and ward-level quality improvement processes, which are subject to ongoing monitoring to ensure improvements continue, I would like to assure you that the oversight and focus on”

    Source location

    Response from Sussex Partnership Foundation Trust
    Page 4 · response
    Published 22 June 2026

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 provide timely access to the Duty Doctor for deteriorating patients

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · 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

    Implement a dedicated NHS wireless network enabling junior doctors’ smartphones to use Wi-Fi calling at identified Kingsmill locations, and distribute user guidance.

    Verbatim wording from the response

    “The option of a “back up bleep” to be an alternative contact method if the mobile phone fails was then considered. Advice from IT was that there is a function to remove bleeping from the NHS, which was to be achieved by the end of 2021. Alternative options include various apps, but they all require a smartphone and a reliable signal or Wi-Fi calling. We have therefore reviewed all first on call rotas to establish all locations where the junior doctor may need to visit as part of their duties. For the duty doctor at Millbrook, in addition to Millbrook itself, this consists of all of Kingsmill Hospital Campus – including Kingsmill Hospital Pathology Lab, along with Alexander House, Bracken House and the road in between. ICT have now developed a solution using Wi-Fi calling via a specific NHS wireless network.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 6 · response
    Published 24 January 2022

    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 crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.

    Verbatim wording from the response

    “The recommendation from the SI report was to have a “crash bleep”. This was considered but discounted as the duty doctor covers a number of geographical sites and cannot provide an immediate response. Therefore, the response to a medical emergency needs to remain as 999.”

    Source location

    2022-0016-Response-from-Nottinghamshire-Healthcare_Published
    Page 5 · response
    Published 24 January 2022

    Open published response

  3. Norfolk

    AI-generated summary

    Ben Buster KING · 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

    Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

    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 contact the respiratory on-call consultant on repeat presentation

    Wider context from the report

    “1. Guidance was sought by Emergency Department (ED) when Ben King attended on 10 July 2020 from a Respiratory Consultant, who was not made aware that Ben King had attended some 6 hours earlier with the same symptoms. 2. The Respiratory on call consultant was not contacted when Mr King returned to NNUH two days later on the 12 July 2020 with the same symptoms. 3. At the time of Ben King’s attendance at NNUH, Ben King was under the Respiratory Team and had been seen a few days earlier, on the 3 July 2020. The Respiratory Team was not made aware of Ben King’s attendances at ED on 9, 10 or 12 July 2020 with respiratory problems ”

    Source location

    Ben Buster KING · 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

    Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.

    Verbatim wording from the response

    “That said, the importance of effective communication is clearly recognised and to promote good quality handovers the Respiratory team now hold a daily morning report meeting, attended by all the on-call specialities. At these meetings cases are discussed and referred to other specialities as appropriate.”

    Source location

    2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
    Page 1 · response
    Published 23 July 2021

    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 further respiratory referral was not considered necessary because the patient had the same symptoms only two days earlier.

    Verbatim wording from the response

    “Our on-call respiratory physicians are available to provide advice to the Emergency Department doctors as required and the ED staff sought such advice with respect to Mr King’s case when he presented on 10 July 2020.”

    Source location

    2021-0250-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
    Page 2 · response
    Published 23 July 2021

    Open published response

  4. Manchester South

    AI-generated summary

    Alison Jean Shirley Jeanes · 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

    Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.

    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 obtain and follow up further haematology advice when INR remains above target

    Wider context from the report

    “3. The inquest heard that haematology advice on the day of admission was to reduce her INR. This advice was reconfirmed by the neuro surgeons the following day. There were differences in the recommendations and it was not entirely clear how that difference was being managed. In any event despite repeated attempts with Vitamin K Mrs Jeanes INR remained above the target. Further advice from the haematologist was not sought until 26th March some 9 days after her admission. It was unclear why that delay had occurred as the notes suggested it had been recognised that advice should have been sought previously but this had not been followed up. There was no evidence before the inquest of what system was in place or who would take responsibility for follow up in such a situation. ”

    Source location

    Alison Jean Shirley Jeanes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 24-hour haematology support, anticoagulation guidance and ward-team responsibilities provide arrangements for INR management and follow-up.

    Verbatim wording from the response

    “Advice from Haematology The requirement is that the on-call or ward team should contact the Haematology specialists at Wythenshawe Hospital should they require advice. Patients should then be referred back to the Anticoagulant Clinic on discharge from hospital for follow-up care. The Trust has a Haematology service which is on-call 24 hours a day, 7 days a week. The Haematology team will advise on appropriate reversal of anticoagulation. It is the ward team’s responsibility to follow-up and action such advice, and to refer back to Haematology should further specialist input be needed in the course of the patient’s admission.”

    Source location

    2020-0200-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted.pdf
    Page 8 · response
    Published 1 December 2020

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Evelyn Ann Swift · 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

    Evelyn Ann Swift became increasingly unwell over several days and contacted her GP surgery repeatedly on 3 January 2019, but a home visit was not arranged until that evening. The assessment was incomplete, her condition was not recognised as severe, and she was not admitted to hospital; she was found deceased at home the following morning. The principal concerns related to unsafe procedures for triage, home-visit allocation, urgent clinical advice, documentation, clinical cover, and review of significant events.

    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

    Unavailability of a daily clinician for practice access and urgent clinical advice

    Wider context from the report

    “3. The Beechdale group did not have an allocated clinician available each day that was accessible by the Practice team, and available to provide urgent clinical advice. ”

    Source location

    Evelyn Ann Swift · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Black Country

    AI-generated summary

    Mr Ronald Compson · 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

    Mr Ronald Compson, who had Parkinson’s disease, was admitted to hospital after confusion and drowsiness and later sustained an unwitnessed fall with a head injury. He subsequently became unresponsive and died from a subdural haematoma; concerns included failure to notify a doctor, vomiting episodes with poor record keeping, and poor communication with his family about the fall.

    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 contact the on-call doctor

    Wider context from the report

    “1. Evidence emerged during the inquest that there was a failure to contact a Doctor and it isn’t clear if this was a system failure through the “nerve centre” system designed to inform the on call Doctor. ”

    Source location

    Mr Ronald Compson · 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

    Complete a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.

    Verbatim wording from the response

    “The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.”

    Source location

    2018-0030-Response-by-Dudley-Group-NHS-Trust
    Page 1 · response
    Published 8 June 2018

    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

    The investigation found no nerve centre system failure; the failure to contact a doctor resulted from human error entering incorrect patient details.

    Verbatim wording from the response

    “The important issues you raise have been taken very seriously and I enclose a summary of the Root Cause Analysis (RCA) investigation undertaken by the Trust regarding these. The investigation has shown that there was no nerve system failure identified, the failure to contact a doctor was as a consequence of human error due to the input of incorrect patient details into the system.”

    Source location

    2018-0030-Response-by-Dudley-Group-NHS-Trust
    Page 1 · response
    Published 8 June 2018

    Open published response

  7. West Sussex

    AI-generated summary

    Jean Stockley · 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 Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.

    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

    Unclear designation of the doctor to contact after an acute NEWS change

    Wider context from the report

    “2. Further, although the nurse quite rightly telephoned a doctor it was far from clear whether the right doctor had been contacted. The national NEWS forms were in use at the time of Mrs Stockley's death to record observations but the policy that governed their use was the 2012 MEWS Escalation Policy and the two policies were different. From evidence heard from both doctors and nurses, it suggests the need to revisit how the NEWS policy is applied locally especially around which doctor should be contacted when there is an acute change. ”

    Source location

    Jean Stockley · 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 revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.

    Verbatim wording from the response

    “2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 August 2016

    Open published response

  8. Bedfordshire and Luton

    AI-generated summary

    Sonielia Laura Caya HOLMES · 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

    Sonielia Laura Caya HOLMES was admitted to Bedford Hospital on 17 April 2013 with confusion and seizures, later suffering a fall that caused a brain bleed. She died from multi-organ failure at 17:06 on 4 May 2013. The principal concerns were repeated failures to contact Haematology doctors and failures to respond to requests for advice and review, despite the use of known contact details.

    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 of the Haematology Department to remain contactable by attending doctors

    Wider context from the report

    “1. That on numerous occasions it proved impossible for the doctors attending Miss Holmes to contact the Haematology Department at the Hospital. This was despite the staff using all known contact details, including mobile phones and bleep numbers. 2. That the Haematologists working within the Hospital failed to respond to messages left for them to offer advice and to review Miss Holmes. 3. It was apparent from the evidence that Haematology is a vital service within the Hospital and any failure to respond to requests for assistance from other clinicians will put lives at risk. ”

    Source location

    Sonielia Laura Caya HOLMES · 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