Concerns raised 3 Failure to ensure Cardiology team awareness and access to the emergency GP telephone number View source Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion View source Failure of Medical Consultants and staff to access the UHCW switchboard View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 3
Action
Develop longer-term technological alternatives for accessing clinical teams and making referrals between organisations.
View source
Action
Circulate a Trust-wide safety practice alert containing the priority UHCW referral telephone number at handovers.
View source
Action
Develop a short-term cross-organisational process for clinical conversations, referrals and escalation safety-netting.
View source
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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. The report was sent to South Warwickshire University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure Cardiology team awareness and access to the emergency GP telephone number
Wider context from the report “(2) A previous incident in which a similar concern had been raised, had led to provision of an emergency GP phone number, that can be used by the clinical teams at SWFT, which is manned 24 hours a day and is prioritised over other calls. The Cardiology team had not been aware of this, nor did they have the telephone number .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Warwickshire University NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion
Wider context from the report “(3) Mr Guillaume was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023 , as the referral had not been completed .
(4) Had the referral been completed, the team at UHCW could have prioritised the patient’s transfer.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to South Warwickshire University NHS Foundation Trust; that does not assign responsibility.
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 .
” Open source report
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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
Open published response
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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 Circulate a Trust-wide safety practice alert containing the priority UHCW referral telephone number at handovers.
Verbatim wording from the response “3 | Safety Practice Alert to be circulated Trust wide with priority telephone number for referrals to UHCW | Safety practice alert to be shared at each handover for 2 weeks. | Patient Safety team SWFT | 06/09/2023 | Action completed 6 September 2023” Source location Response from South Warwickshire University NHS Foundation Trust
Open published response
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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
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations