Unreliable consultant attendance when clinically required
First to latest report 29 Sep 2015 — 30 Aug 2024
Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
7
What this concern includes
Includes failures of the on-call consultant attendance arrangement, including unavailability, delayed attendance, or failure to ensure attendance when requested, where the report links the failure to required clinical care.
What is not included
Excludes generic shortages or staffing concerns that are not specifically tied to on-call consultant attendance.
Excludes failures of consultant supervision, advice or review where attendance is not part of the reported unsafe condition.
Excludes attendance by non-consultant staff, specialist teams or emergency services unless the report explicitly concerns the on-call consultant attendance arrangement.
Excludes individual clinical decisions made after an available consultant has attended or been contacted.
Trends
Reports over time
Reports mentioning this concern, 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.
NHS England3
Department of Health and Social Care2
British Association of Perinatal Medicine1
Care Quality Commission1
East Kent Hospitals University NHS Foundation Trust1
General Medical Council1
Greater Manchester Combined Authority1
Maidstone and Tunbridge Wells NHS Trust1
Milton Keynes University Hospital1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Royal College of Paediatrics and Child Health1
Sheffield Teaching Hospitals NHS Foundation Trust1
University Hospitals Sussex NHS Foundation Trust1
NHS trust4
Executive non-departmental public body3
Health professional body2
Ministerial department2
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Mayoral policing body1
Professional body1
Type not available1
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
West Sussex, Brighton and Hove
Concerns raised1
Variability in on-call Neonatology Consultant attendance times
Linked responses
British Association of Perinatal Medicine
NHS England
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
University Hospitals Sussex NHS Foundation Trust
Explore options for establishing a separate Neonatal Consultant on-call rota for the Princess Royal Hospital Special Care Baby Unit.
University Hospitals Sussex NHS Foundation Trust
Approach the Integrated Care Board about externally reviewing current arrangements and options to strengthen Neonatal Consultant on-call provision for the Princess Royal Hospital service.
British Association of Perinatal Medicine
Recommend against simultaneous out-of-hours cover of geographically separate neonatal sites and concurrent Tier 2 and Tier 3 cover by one consultant.
British Association of Perinatal Medicine
Publish recommendations requiring immediate consultant availability, attendance within 30 minutes, and robustly job-planned and risk-assessed local coverage arrangements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
University Hospitals Sussex NHS Foundation Trust
Outcome reviews found no evidence that the current Neonatal Consultant on-call arrangements at Princess Royal Hospital are unsafe or contribute to neonatal deaths.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
University Hospitals Sussex NHS Foundation Trust
The Trust cannot currently provide a separate Princess Royal Hospital rota because Consultant, workforce and financial resources are unavailable.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
University Hospitals Sussex NHS Foundation Trust
The Trust is asking the Integrated Care Board to externally review current arrangements and options for strengthening Neonatal Consultant on-call provision.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
NHS Trusts determine their own out-of-hours neonatal consultant response-time policies under consultants’ terms and conditions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
British Association of Perinatal Medicine
BAPM guidance contains no recommendation specifying the time consultants must be on site.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
British Association of Perinatal Medicine
BAPM is advisory rather than executive and therefore cannot direct trusts' local implementation processes.
Outside remitThe respondent said that this matter was outside its role or authority.
British Association of Perinatal Medicine
Individual trusts are responsible for implementing local processes in line with national guidelines.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Reliance on consultants who may be non-resident on call during neonatal resuscitation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Royal College of Paediatrics and Child Health
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Royal College of Paediatrics and Child Health
Mandatory non-invasive airway skills, readiness assessment, consultant support and current Newborn Life Support status provide safe preparation for neonatal resuscitation.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North East Kent
Concerns raised1
Insufficient consultant availability for night-time emergencies
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
The CQC is responsible for deciding and providing further detail on regulatory action concerning the Trust’s maternity-service safety risks.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised1
Unavailability of the on-call consultant for prompt attendance
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Teaching 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
Sheffield Teaching Hospitals NHS Foundation Trust
On-call doctors must be able to attend within 30 minutes and consultants living farther away must arrange suitable local accommodation while on call.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Mid Kent and Medway
Concerns raised1
Unavailability of a surgical consultant on call from Maidstone during the working week
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Maidstone and Tunbridge Wells NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Maidstone and Tunbridge Wells NHS Trust
A consultant general surgeon is always on call and accessible, although weekday cover is predominantly based at Tunbridge Wells.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
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.
Linked response
Milton Keynes University Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Milton Keynes University Hospital NHS Foundation Trust
Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.
Milton Keynes University Hospital NHS Foundation Trust
Embed a revised SBAR handover communication tool in practice.
Milton Keynes University Hospital NHS Foundation Trust
Recirculate the written escalation policy to all staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Milton Keynes University Hospital NHS Foundation Trust
The CTG did not require immediate intervention, and staff escalated appropriately when the doctor did not attend within a reasonable timescale.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes University Hospital NHS Foundation Trust
The consultant attended within 14 minutes, which was considered appropriate for the case concerned.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes University Hospital NHS Foundation Trust
Clear escalation instructions already exist for all midwifery and medical staff, including escalation to a consultant.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.