Recurring concern

Failure to provide timely specialist review in emergency departments

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First reported 6 Nov 2013•Latest report 28 Jun 2023

Definition

What this concern includes

Includes failures of the Emergency Department process for obtaining timely specialist review when clinically needed, including on-call specialty assessment and early paediatrician review for very young children, whether the failure concerns availability, escalation, referral or timing.

Not included

Excludes generic Emergency Department staffing, crowding or waiting-time deficiencies unless they directly prevent required specialist review.
Excludes delays or failures in consultant review outside the Emergency Department specialist-review process.
Excludes failures involving specialist advice or review after the patient has left the Emergency Department unless the assertion concerns the Emergency Department review pathway.
Excludes generic referral, communication or training deficiencies that are not directly tied to obtaining required Emergency Department specialist review.

Reports: 5
Individual concerns: 6
Date range: 2013–2023
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Bedfordshire Hospitals NHS Foundation Trust1

Blackpool Teaching Hospitals NHS Foundation Trust1

Greater Manchester Combined Authority1

NHS England1

Royal Bolton Hospital1

University Hospitals Birmingham NHS Foundation 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.

28 Jun2023
Birmingham and Solihull
Concerns raised1
1. Failure to escalate eligible emergency department patients for consultant review
This report raised 4 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 3
1. Action
  Implement a policy empowering any multiprofessional team member to escalate delayed assessment or transfer to the consultant on call.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Deliver an education programme on escalation for delayed assessment or transfer from August 2023.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated in progress
3. Action
  Deliver direct teaching and display laminated posters in acute surgical areas at all acute sites by 31 October 2023.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.
  Stated by University Hospitals Birmingham NHS Foundation TrustRedirects responsibility
AI-generated summary

Hilary THOMAS · 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

Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.

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 escalate eligible emergency department patients for consultant review
Wider context from the report
“2. Mrs Thomas reattended hospital with severe pain, was over age 70 and an unscheduled return within 72 hours. The Doctor should have considered and followed national guidance from the Royal College of Emergency medicine published in June 2016 (consultant sign off) which confirmed Mrs Thomas should have been reviewed by a consultant. Mrs Thomas was not escalated for consultant review. There was no evidence at the inquest that this guidance has been adopted by the Trust nor that staff are aware of it and have been trained on it. ”
Source location
Hilary THOMAS · 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 policy empowering any multiprofessional team member to escalate delayed assessment or transfer to the consultant on call.

Verbatim wording from the response
“The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

Source location
Response University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 7 July 2023
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
Deliver an education programme on escalation for delayed assessment or transfer from August 2023.

Verbatim wording from the response
“The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

Source location
Response University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 7 July 2023
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
Deliver direct teaching and display laminated posters in acute surgical areas at all acute sites by 31 October 2023.

Verbatim wording from the response
“The Trust has therefore implemented a new policy developed by the Clinical Service Leads for EGS and ED, alongside a programme of education (from August 2023) in which any member of the multi-professional team are invited to escalate concerns regarding delayed assessment, or delayed transfer of patients to SAU, to the consultant on call. This will be enhanced by a communication strategy that will include direct teaching and laminated posters displayed in acute surgical areas at all acute sites (by 31 October 2023). This communication will emphasise the importance of this action for patient safety and will not be a punitive action.”

Source location
Response University Hospitals Birmingham NHS Foundation Trust
Page 3 · response
Published 7 July 2023
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
Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.

Verbatim wording from the response
“This area of concern is for the Department of Health and Social Care however we acknowledge that there has been a significant increase in demand for assessment by the Emergency General Surgery (EGS) Service at UHB. This was the service to which Mrs Thomas was appropriately referred by the Emergency Department. In this case failure of assessment and escalation occurred after this referral. She was seen by the EGS service at 11:30am by an experienced Specialist Registrar (SpR) who was in the 7th Year of specialist training (ST7). When that SpR returned at 20:00 Mrs Thomas, after waiting for so long, had taken her own discharge. We acknowledge that Mrs Thomas had to wait far too long and that this was a failure of the EGS service.”

Source location
Response University Hospitals Birmingham NHS Foundation Trust
Page 2 · response
Published 7 July 2023
Open published response
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. Failure to provide on-call specialist review in the Emergency Department when needed
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.
  Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Douglas OWENS · 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

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 on-call specialist review in the Emergency Department when needed
Wider context from the report
“(2) That the Deceased was not seen by a speciality doctor in the Emergency Department notwithstanding the need for him to be seen. Unless action is taken there may be a continuing risk that patients in the Emergency Department will not be seen by on call doctors in speciality disciplines, in particular, ophthalmology, even when the need arises in that Department. ”
Source location
Douglas OWENS · 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
Develop and implement an ophthalmology emergency protocol covering handover, internal patient pathways and specialty attendance in the Emergency Department.

Verbatim wording from the response
“The matter of an agreement with Spire Fylde Coast Hospital for the urgent transfer of patients to the Ophthalmic Unit at Blackpool Victoria Hospital has been considered and discussed at length with relevant consultant colleagues. After much deliberation, it was felt that an agreement with Spire Fylde Coast Hospital may not be sufficient to prevent similar incidents from occurring and thus the focus was directed to the development of more responsive and effective protocols in our existing services, to ensure that handover from Spire Fylde Coast Hospital to the Emergency Department (ED) and then ophthalmology would be performed quickly and comprehensively.”

Source location
2020-0210-Response-from-Blackpool-Teaching-Hospitals_Redacted.pdf
Page 1 · response
Published 3 December 2020
Open published response
10 Feb2020
Bedfordshire and Luton
Concerns raised1
1. Failure to provide timely Medical Team review and diagnostic support after referral
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.
AI-generated summary

Sarah YOUNG · 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

Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

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 Medical Team review and diagnostic support after referral
Wider context from the report
“(1) Although Sarah was referred to the Medical Team at 20:00 on 9 April 2019 whilst she still in the Emergency Department awaiting the CT venogram, she was never seen by them. The evidence to the Inquest from the Medical Registrar on call that evening was that “if a decision to admit to ITU is made, an immediate or urgent medical review is not required, as the patient is under the direct care of the ITU team” yet the evidence from one of the ITU Consultants in charge of her care was that the ITU Team do rely on the Medical Team to assist in progressing a diagnosis( including involving a Neurologist where required) and that it was a matter of regret for him that there had not been more Medical advice in this case; ”
Source location
Sarah YOUNG · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Apr2018
Manchester South
Concerns raised2
1. Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care
2. Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
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 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.
AI-generated summary

Novia Emilia Delima · 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

Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.

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 systems ensuring early paediatrician review of very young children in out-of-hours emergency department care
Wider context from the report
“2. The inquest heard that very young babies present significant challenges in diagnosis and early clinical input by a clinician experienced in dealing with young children was important. The trust had brought in significant changes to how it dealt with paediatric cases in ED since the death of Novia. This includes early clinical involvement of a paediatric clinician for babies between 0- 6 months due to their recognition of challenges of diagnosis in very young children. The inquest heard that not all trusts, nationally, have systems that ensure very young children are seen by a paediatrician at an early stage particularly in an OOH situation. ”
Source location
Novia Emilia Delima · Prevention of Future Deaths report
Page 2 · 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 of emergency department on-call arrangements to trigger consultant attendance after long waits
Wider context from the report
“3.on the night in question the inquest heard that a consultant was on call for ED but was not called in despite the significant delays in ED. The inquest heard that the ED on call consultant arrangements meant that long wait times would not in themselves trigger on call consultants being asked to attend the hospital. ”
Source location
Novia Emilia Delima · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Nov2013
Manchester South
Concerns raised1
1. Lack of direct orthopaedic input at the Emergency Department
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 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.
AI-generated summary

William Joseph Wilkinson · 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

William Joseph Wilkinson slipped on the pavement while shopping on or about 9 December 2012, fractured his ankle, was admitted to hospital, and later died after complications. Concerns included the availability of ordered one-to-one nursing, difficulties logging onto the hospital computer system, an incomplete Fluid Balance Chart, and the lack of direct orthopaedic input in the Emergency Department.

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 direct orthopaedic input at the Emergency Department
Wider context from the report
“(4) It was agreed that there was no direct orthopaedic input available at the Emergency Department at the hospital and that it would be sensible for this to have been available. Had this been available Mr Wilkinson would probably not have been admitted to the hospital in the first place with a fractured ankle and therefore would not, presumably, have developed clostridium difficile leading to his death. He was described as an unnecessary in-patient. ”
Source location
William Joseph Wilkinson · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to escalate eligible emergency department patients for consultant review

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide on-call specialist review in the Emergency Department when needed

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

Concerns raised1

Failure to provide timely Medical Team review and diagnostic support after referral

Concerns raised2

Lack of systems ensuring early paediatrician review of very young children in out-of-hours emergency department care

Failure of emergency department on-call arrangements to trigger consultant attendance after long waits

Concerns raised1

Lack of direct orthopaedic input at the Emergency Department

Actions described in response 3

Respondent positions 1

Actions described in response 1