Recurring concern

Unreliable duty system arrangements for safe clinical coverage

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First reported 7 Sep 2016•Latest report 20 Oct 2023

Definition

What this concern includes

Includes failures in explicitly identified duty-system arrangements that affect safe clinical coverage, including inadequate robustness, insufficient time within duty-doctor arrangements, unclear coverage or operational weaknesses that leave patients without an effective duty response.

Not included

Excludes generic staffing, workload or workforce-capacity concerns where no duty-system arrangement is identified.
Excludes individual clinical assessment, treatment or escalation failures that are not part of a deficient duty system.
Excludes ordinary shift, rota or break arrangements where they do not affect the safety or effectiveness of duty-system clinical coverage.
Excludes non-clinical duty systems and operational command arrangements unrelated to clinical patient coverage.

Reports: 3
Individual concerns: 3
Date range: 2016–2023
Stated actions: 2

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.

Church Lane Surgery1

Department of Health and Social Care1

Devon Partnership NHS Trust1

NHS Devon Integrated Care Board1

Northwick Park Hospital1

Nottinghamshire Healthcare 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.

20 Oct2023
Inner North London
Concerns raised1
1. Insufficient time in the duty doctor system to deal with patients appropriately
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.
Actions described in response 1
1. Action
  Add three unbooked telephone slots and three face-to-face slots to each duty doctor’s shift.
  Stated by Church Lane SurgeryStated completed
AI-generated summary

Trevor Coy BAILEY · 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

Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.

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 time in the duty doctor system to deal with patients appropriately
Wider context from the report
“2. ████████ told me in the witness box that she had identified immediately after Mr Bailey’s death in May 2023 that the duty doctor system at Church Lane Surgery does not allow sufficient time to deal with patients appropriately. However, she has not progressed this issue in the five months since. ”
Source location
Trevor Coy BAILEY · 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
Add three unbooked telephone slots and three face-to-face slots to each duty doctor’s shift.

Verbatim wording from the response
“2. Actions to re-structure the On-call system for the Duty doctor.”

Source location
Response from Chuch Lane Surgery
Page 3 · response
Published 6 November 2023
Open published response
19 Jan2022
Nottinghamshire
Concerns raised1
1. 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. 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 TrustStated completed
Respondent positions 1
1. 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 TrustUnable to act
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
7 Sep2016
Exeter and Greater Devon
Concerns raised1
1. Failure of effective and robust duty system arrangements
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Louise Turner · 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

Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.

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 effective and robust duty system arrangements
Wider context from the report
“(2) The duty system arrangements and buddying system referred to at Inquest were not effective or robust and need to be reconsidered in the light of the outcome of this case. ”
Source location
Louise Turner · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient time in the duty doctor system to deal with patients appropriately

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 access to the Duty Doctor for deteriorating patients

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

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

Concerns raised1

Failure of effective and robust duty system arrangements

Actions described in response 1

Actions described in response 1

Respondent positions 1