Recipient

South Warwickshire University NHS Foundation Trust

First report 29 Dec 2023•Latest report 29 Dec 2023

Recipient record

Reports, concerns and published responses

Health and care · NHS trust. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 400%
Concerns addressed: 10
Stated actions: 32

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

400%published responses found

32stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from South Warwickshire University NHS Foundation Trust linked to the concerns in each report. Select any concern, action or position to view the source wording.

29 Dec2023
Coventry and Warwickshire
Concerns raised3
1. Failure to ensure Cardiology team awareness and access to the emergency GP telephone number
2. Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion
3. Failure of Medical Consultants and staff to access the UHCW switchboard
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Develop longer-term technological alternatives for accessing clinical teams and making referrals between organisations.
  Stated in progress
2. Action
  Circulate a Trust-wide safety practice alert containing the priority UHCW referral telephone number at handovers.
  Stated completed
3. Action
  Develop a short-term cross-organisational process for clinical conversations, referrals and escalation safety-netting.
  Stated in progress
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
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 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
Page 4 · 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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to ensure Cardiology team awareness and access to the emergency GP telephone number

Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion

Failure of Medical Consultants and staff to access the UHCW switchboard

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

Actions described in response 3