Recurring concern

Unreliable hospital switchboard access and handling of urgent clinical requests

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First reported 4 Nov 2014•Latest report 29 Dec 2023

Definition

What this concern includes

Includes failures in hospital switchboard arrangements involving access, call routing, recording, escalation, follow-up or coordination of urgent clinical and specialist-care requests, including delayed contact with tertiary services and requests that may otherwise go unanswered.

Not included

Excludes general clinical communication, referral or on-call contact failures where the hospital switchboard is not the deficient process.
Excludes downstream clinical assessment, treatment or specialist-care failures after a request has been reliably routed and followed up.
Excludes generic telephone outages or public emergency-call failures outside a hospital switchboard context.
Excludes failures limited to routine non-urgent administrative calls without a patient-safety or urgent-care consequence.

Reports: 3
Individual concerns: 3
Date range: 2014–2023
Stated actions: 5

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.

Blackpool Teaching Hospitals NHS Foundation Trust1

Care Quality Commission1

Department of Health and Social Care1

NHS England1

Parents of Tommi-Ray Colin Vigrass1

South Warwickshire University NHS Foundation Trust1

University Hospitals Coventry and Warwickshire NHS Trust1

Walsall Healthcare NHS 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.

29 Dec2023
Coventry and Warwickshire
Concerns raised1
1. Failure of Medical Consultants and staff to access the UHCW switchboard
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.
Actions described in response 4
1. Action
  Establish a 24-hour, seven-day direct communication escalation process.
  Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completed
2. Action
  Share the confirmed escalation arrangement with other providers across the system.
  Stated by University Hospitals Coventry and Warwickshire NHS TrustStated planned
3. Action
  Develop a short-term cross-organisational process for clinical conversations, referrals and escalation safety-netting.
  Stated by South Warwickshire University NHS Foundation TrustStated in progress
1. Action
  Develop longer-term technological alternatives for accessing clinical teams and making referrals between organisations.
  Stated by South Warwickshire University NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  The concerns predominantly fall within the relevant NHS trusts’ remit, including UHCW, so they should be addressed to those trusts.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Responsibility for addressing communication about patient-transfer referrals primarily rests with the Trusts involved.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Andrew Douglas Guillaume · 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

Andrew Douglas Guillaume was admitted to Warwick Hospital on 5 June 2023 with shortness of breath and a cough, and was later assessed as likely having severe aortic stenosis requiring urgent referral. He deteriorated, was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, and died on 20 June 2023; concerns included difficulties contacting the UHCW switchboard, lack of awareness of an emergency contact number, and the absence of a completed referral preventing discussion at a multi-disciplinary meeting.

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 Medical Consultants and staff to access the UHCW switchboard
Wider context from the report
“(1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions. ”
Source location
Andrew Douglas Guillaume · 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
Establish a 24-hour, seven-day direct communication escalation process.

Verbatim wording from the response
“We have agreed to explore the technological options that may improve this however, in the interim we have agreed an escalation process that now provides a direct line of communication 24 hours, seven days per week.”

Source location
Response from University Hospitals Conventry and Warwickshire NHS Trust
Page 1 · response
Published 3 January 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
Share the confirmed escalation arrangement with other providers across the system.

Verbatim wording from the response
“This arrangement has been confirmed with SWUFT following the tabletop review and we will also share this with the other Providers across the System. We hope this provides assurances, and I would like to assure you that we will continue to explore communication improvements as part of our digital plans.”

Source location
Response from University Hospitals Conventry and Warwickshire NHS Trust
Page 1 · response
Published 3 January 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
Develop a short-term cross-organisational process for clinical conversations, referrals and escalation safety-netting.

Verbatim wording from the response
“In addition to the work that had been carried out in response to the Serious Incident (SI) Review, the meeting identified work streams/themes which will be progressed by the two organisations. These include both short and longer term work to improve communications between SWFT and UHCW. Although many of these are still a work in progress I will, obviously, be happy to keep you updated.”

Source location
Response from South Warwickshire University NHS Foundation Trust
Page 2 · response
Published 3 January 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
Develop longer-term technological alternatives for accessing clinical teams and making referrals between organisations.

Verbatim wording from the response
“In addition to the work that had been carried out in response to the Serious Incident (SI) Review, the meeting identified work streams/themes which will be progressed by the two organisations. These include both short and longer term work to improve communications between SWFT and UHCW. Although many of these are still a work in progress I will, obviously, be happy to keep you updated.”

Source location
Response from South Warwickshire University NHS Foundation Trust
Page 2 · response
Published 3 January 2024
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
The concerns predominantly fall within the relevant NHS trusts’ remit, including UHCW, so they should be addressed to those trusts.

Verbatim wording from the response
“The matters of concern raised in your Report predominantly fall under the remit of the relevant Trusts, South Warwickshire University NHS Foundation Trust (SWFT) and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). I note that you have addressed your Report to SWFT, but you may also wish to address your concerns to UHCW.”

Source location
Response from NHS England
Page 1 · response
Published 3 January 2024
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 communication about patient-transfer referrals primarily rests with the Trusts involved.

Verbatim wording from the response
“The matters of concern raised are primarily for the Trusts to address, and I note both the South Warwickshire University NHS Foundation Trust (SWFT) and the University Hospitals Coventry and Warwickshire NHS Trust (UHCW) have addressed your concerns in detail in their responses. Local collaborations and working options are being explored to develop long term technological solution and short-term measures so this does not happen again. Several recommendations and actions have also been completed by the SWFT which address your concerns directly. I also note that NHS England has replied and are sighted on the issues you raised.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 3 January 2024
Open published response
28 Jun2016
Black Country
Concerns raised1
1. Delays and problems in contacting the tertiary unit through the switchboard
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 1
1. Action
  Establish an out-of-hours Regional Cot Locator service to facilitate contact with tertiary neonatal units.
  Stated by Walsall Healthcare NHS TrustStated completed
AI-generated summary

Tommi-Ray Colin Vigrass · 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

Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.

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
Delays and problems in contacting the tertiary unit through the switchboard
Wider context from the report
“2. In addition, it emerged that there were problems and delays in trying to contact the tertiary unit via the switchboard. ”
Source location
Tommi-Ray Colin Vigrass · Prevention of Future Deaths report
Page 3 · 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
Establish an out-of-hours Regional Cot Locator service to facilitate contact with tertiary neonatal units.

Verbatim wording from the response
“2. You may also wish to consider expediting the process to establish a system to contact tertiary units within our area to minimise any delays in contacting the relevant staff for advice.”

Source location
2016-0241-Response-by-Walsall-Healthcare-NHS-Trust
Page 3 · response
Published 8 June 2016
Open published response
4 Nov2014
Blackpool and the Fylde
Concerns raised1
1. Failure of Hospital Switchboard procedures to ensure follow-up of urgent specialist care requests
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

Mark Bentley Hudson · 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

Mark Bentley Hudson was admitted to hospital for chest pain, underwent urgent coronary artery bypass surgery, and later suffered cardiac arrests. During the second arrest, specialist assistance was delayed or may not have been contacted, and an oesophageal intubation went unrecognised; the concern was that procedures for urgent CICU requests via the switchboard were not sufficiently robust.

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 Hospital Switchboard procedures to ensure follow-up of urgent specialist care requests
Wider context from the report
“Although encouraged by the steps that have been / are being taken internally at the Hospital further to this death, I remain concerned that there is a real risk that when the need arises for urgent provision of specialist care within the CICU department, such requests may go unanswered or be delayed. If CICU staff request such assistance via the Hospital Switchboard personnel at the hospital, I am concerned that the procedures in place are insufficiently robust to the extent that requests may not be followed up appropriately and to the potential detriment of the Patient requiring that urgent help. ”
Source location
Mark Bentley Hudson · 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

Failure of Medical Consultants and staff to access the UHCW switchboard

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Delays and problems in contacting the tertiary unit through the switchboard

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 of Hospital Switchboard procedures to ensure follow-up of urgent specialist care requests

Actions described in response 4

Respondent positions 2

Actions described in response 1