Recurring concern

Unreliable hospital bleep systems for urgent clinical communication

First to latest report 19 Sep 2020 — 1 Mar 2024

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
5

What this concern includes

Includes failures of hospital bleep systems used for urgent clinical communication or emergency alerts, including unavailable devices, inability to transmit sufficient information electronically, unreliable operation and failure of the system to support prompt alerting of the responsible clinical team.

What is not included
  • Excludes generic communication, handover or task-prioritisation failures where no hospital bleep-system deficiency is identified.
  • Excludes failures of ambulance, police, fire or other emergency-service communication systems unless the assertion specifically concerns a hospital bleep system.
  • Excludes failures to respond to a correctly received bleep where the bleep system itself operated reliably.
  • Excludes generic staff training or workflow deficiencies where the hospital bleep system is not the deficient control.

Reports and published responses 3 reports

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

  1. North Wales (East and Central)

    AI-generated summary

    Jennifer Ann Trigger · 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

    Jennifer Ann Trigger was admitted to Wrexham Maelor Hospital on 29 January 2020 after suffering an acute stroke and was prescribed beriplex, a time-critical treatment, which was not administered until the following morning. The report identified miscommunication and limitations in the bleep system as contributing to delays in prioritising and administering the treatment, followed by deterioration in her condition and her death on 31 January 2020.

    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 bleep system to convey information electronically

    Wider context from the report

    “There was a miscommunication or misunderstanding when a ward nurse bleeped a junior doctor with a view to action being taken in relation to the administration of the beriplex infusion. This resulted in a delay in the doctor attending as she did not prioritise a task which was time critical and the subsequent delays resulted in an unrecoverable deterioration in the patient’s condition. Evidence was received in the course of the inquest that the current bleep system did not enable information to be conveyed electronically and that this in turn created a risk of misunderstanding as to work requirements and hence impacted upon prioritisation of tasks and therefore potential delays, the effects of which (as in this case) could be catastrophic in terms of patient safety. Evidence was also given that alternative systems existed that had the potential for mitigating or eliminating such risk by way of the electronic transfer of information and requests to doctors. ”

    Source location

    Jennifer Ann Trigger · Prevention of Future Deaths report
    Page 1 · 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

    Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.

    Verbatim wording from the response

    “The Health Board has been working on a paging system replacement and upgrade project for 12 months.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 6 March 2024

    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

    Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.

    Verbatim wording from the response

    “The project involves the replacement of existing on-site paging at Ysbyty Gwynedd in Bangor with an integrated critical messaging service, as part of an overall solution with Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 1 · response
    Published 6 March 2024

    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

    Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.

    Verbatim wording from the response

    “The new Multitone iMessage critical messaging system will improve resilience and will provide standardisation across the 3 general hospitals and switchboards, and will allow for inter-site paging and cross cover arrangements.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 6 March 2024

    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

    Decide the specific future communication solution using the results of technical testing with frontline clinicians.

    Verbatim wording from the response

    “The ongoing improvements in our systems will improve on site communication for staff to support patient referral, transfers, treatment and discharge and improve efficiencies. A number of technical options are being tested to achieve this, with the testing informing a decision on the specific future solution. These options include WiFi telephones (being tested with ward managers and matrons at Ysbyty Gwynedd) and smart phone devices with the Microsoft Teams and Cisco apps to enable calls and instant messaging through our network (being tested with 34 medical staff in Ysbyty Gwynedd). As with any new technology, it is vital we test the options with front line clinicians to inform the best solution and to ensure patient safety.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 6 March 2024

    Open published response

  2. Norfolk

    AI-generated summary

    Bonnie Rose WEBSTER · 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

    Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

    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 use the emergency bleep system to alert the paediatric team

    Wider context from the report

    “3. Evidence was heard that staff alerted the paediatric team on foot, rather than using the emergency "bleep" system. ”

    Source location

    Bonnie Rose WEBSTER · 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

    The Trust found no measurable efficiency difference between notifying paediatric staff in person and using the emergency bleep system.

    Verbatim wording from the response

    “Due to the theatre being immediately adjacent to NICU there was no measurable difference in efficiency between using the "bleep" system and notifying the paediatric team in person. All clinical staff are trained on using the "bleep" system and at any time there will be multiple staff members in theatre able to make this call, rather than this responsibility resting on one”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 2 · response
    Published 25 November 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

    Existing trained staff, emergency-call arrangements and resuscitation cover were considered to mitigate risk, so no system change was required.

    Verbatim wording from the response

    “We recognise that for the runner to have been unable to make the call there is potential additional clinical risk, but we consider that the risk is fully mitigated; firstly, by the fact that in default there are other staff in theatre other than the runner who can do call the emergency number. Secondly, on all occasions where a non-elective caesarean section is being performed, staff trained in resuscitation, namely midwives and junior paediatric staff, are present before birth takes place. We therefore do not think that any change to our system is required with reference to additional appropriately qualified staff being present at birth or securing the attendance of the Consultant Paediatrician.”

    Source location

    Response from The Queen Elizabeth Hospital King's Lynn
    Page 3 · response
    Published 25 November 2022

    Open published response

  3. Essex

    AI-generated summary

    Frederick Joseph Terry · 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

    Baby Frederick Joseph Terry was delivered by caesarean section after a failed forceps attempt on 16 November 2019, and death was confirmed after 40 minutes of resuscitation attempts. The stated cause of death was hypovolaemic shock due to skull fracture, scalp laceration and haemorrhage arising from birth trauma. Concerns included risk assessment and forceps delivery, excessive force and traction, staff training and levels, communication, record keeping, resuscitation equipment and procedures, and neonatal unit support.

    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 bleep in the neonatal unit

    Wider context from the report

    “The need for a bleep in the neonatal unit ”

    Source location

    Frederick Joseph Terry · 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

    Provide the neonatal unit senior nurse with a 24-hour bleep linked to the Code Blue emergency call.

    Verbatim wording from the response

    “Processes have been strengthened with a specific Obstetrics and Gynaecology locum checklist in place, with one additional paid hour to complete and a self-assessment tool for obstetric technical skills has been added to the locum recruitment vetting process. The Trust has also employed a further Obstetric Consultant on a 1 year basis (whilst MSE reconfiguration in place). The Senior Nurse in the Neonatal unit now carries a 24 hour bleep and is summoned as required using the ‘Code Blue’ emergency call.”

    Source location

    2020-0173-Response-from-Mid-and-South-Essex-Foundation-Trust-Redacted.pdf
    Page 2 · response
    Published 16 November 2020

    Open published response

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