Recurring concern
Failure to provide requested on-call clinical review
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Request correctionFirst reported 27 Nov 2013•Latest report 19 Dec 2023
What this concern includes
Includes failures of the dedicated on-call process to respond to requests for patient review or clinical advice, including non-attendance, unresponsiveness, refusal to attend or failure to provide the requested review by registrars or on-call specialty clinicians.
Not included
- Excludes delays in routine or pre-arranged consultant review where no request for on-call clinical input is involved.
- Excludes generic staffing shortages, workload or inadequate cover unless they directly result in failure to respond to a requested on-call review.
- Excludes failures of clinical decisions after the requested review has been completed.
- Excludes failures limited to emergency call triage, ambulance response or other escalation processes where on-call clinical review is not the deficient control.
- Reports
- 9
- Individual concerns
- 9
- Date range
- 2013–2023
- Stated actions
- 14
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
Failure of on-call orthopaedic doctors to attend requested reviews
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 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 provide timely psychiatric doctor assessment when requested
This report raised 18 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
Improve junior and trainee doctor induction to cover escalation of psychiatric and physical health concerns.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Implement improvements to the clinical handover format.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Lack of a policy directing specialty registrar responses to out-of-hours assessment requests
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
Update UGPC streaming guidance and add an addendum requiring clinician agreement or documented disagreement followed by immediate ED referral under Mandy’s Rule.
Stated by Bedfordshire Hospitals NHS Foundation Trust
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Concerns raised1
Failure of the on-call Registrar to review a patient when called for advice
This report raised 10 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 of on-call medical staff to respond reliably to requests to attend patients
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.4
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Action
Redesign the clinical escalation pathway to provide a compliant seven-day service and increase medical cover.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Implement the Urgent and Emergency Pathway Reset programme and use a dedicated project team to improve timely medical access and workforce capacity.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Use bleep tracking and smartphone video calling to track and improve access to on-call medical staff.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Action
Audit escalation through NEWS and incident reporting, provide feedback on failures, and empower nurses to contact consultants when local escalation fails.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
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 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
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 Trust
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Concerns raised1
Failure to chase up requested doctor attendance and review
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 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 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 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.3
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Action
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Embed a revised SBAR handover communication tool in practice.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
Action
Recirculate the written escalation policy to all staff.
Stated by Milton Keynes University Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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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 Trust
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Position
The consultant attended within 14 minutes, which was considered appropriate for the case concerned.
Stated by Milton Keynes University Hospital NHS Foundation Trust -
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 Trust
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Concerns raised1
Unavailability of Doctors for nursing requests for review
This report raised 9 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.3
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Action
Introduce a hospital referral procedure covering Emergency Department referrals.
Stated by Frimley Health NHS Foundation Trust -
Action
Implement electronic Smartphone referral notifications with Specialist Registrar allocation and a one-hour inpatient-team review goal.
Stated by Frimley Health NHS Foundation Trust -
Action
Establish a 24-hour Central Hub with patient tracking, referral and bleep management, workload oversight, handover, task allocation, escalation and senior-manager staffing.
Stated by Frimley Health NHS Foundation Trust
Data last updated 7 September 2026