PFD report

Michael Andrew Pollard · Prevention of Future Deaths report

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Issued 5 Mar 2015•Leicester City and South Leicestershire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to maintain an up-to-date and accessible on-call rota
    Part of recurring concern: Unsafe on-call consultant rota arrangements
  2. Failure to restrict on-call rota amendments to a single central point
    Part of recurring concern: Unsafe on-call consultant rota arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Procure a Trust-wide web-based system to manage on-call rotas.

    Stated by University Hospitals of Leicester NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2015.
  2. Action

    Review the on-call rota system through the Switchboard Management Team.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 March 2015.
  3. Action

    Remind all doctors of their responsibility to notify Switchboard about on-call rota amendments.

    Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    A central amendment point and clinician access process already address the need for accurate, accessible on-call rota information.

    Stated by University Hospitals of Leicester NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain an up-to-date and accessible on-call rota

Wider context from the report

“During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future. In my opinion the following matters need to be considered (1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it (2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota (3) ”

Is this part of a recurring concern?

Yes — Unsafe on-call consultant rota arrangements.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to restrict on-call rota amendments to a single central point

Wider context from the report

“During the night Michael died, it was necessary to contact the on call GI bleed Consultant to discuss the need for an emergency endoscopy. This is accomplished via the hospital switchboard. The rota held by the switchboard staff was out of date, and they called a Consultant who was not on call and was on leave, travelling to the airport at the time. Time was lost in identifying the appropriate Consultant. I was advised that the Trust have not yet resolved a new system to avoid such difficulties in the future. In my opinion the following matters need to be considered (1) The on call rota must be up to date, accessible by both switchboard and those clinicians who need access to it (2) Any amendments must only be made centrally to a single point to avoid any discrepancies between previous rotas and the current rota (3) ”

Is this part of a recurring concern?

Yes — Unsafe on-call consultant rota arrangements.

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

Procure a Trust-wide web-based system to manage on-call rotas.

Verbatim wording from the response

“The Trust is in the process of procuring a trust-wide web-based system to manage our on-call rotas. Our Chief Medical Information Officer expects to have this system available for use throughout the Trust by the end of this calendar year. Once adopted this system should strengthen and improve our processes with information being uploaded in real-time and visible to clinicians.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

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

Review the on-call rota system through the Switchboard Management Team.

Verbatim wording from the response

“As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported to our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and I can confirm that this will occur here.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

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

Remind all doctors of their responsibility to notify Switchboard about on-call rota amendments.

Verbatim wording from the response

“As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

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

Remind Switchboard staff of their responsibility to keep the on-call rota updated.

Verbatim wording from the response

“As a result of this inquest our Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the on-call rota and our Director of Estates and Facilities will, by the end of May 2015, ensure that the switchboard staff are again reminded of their responsibilities to keep the on-call rota updated.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

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

A central amendment point and clinician access process already address the need for accurate, accessible on-call rota information.

Verbatim wording from the response

“Clinicians who need to access the on-call information can do so via Switchboard.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Report the review’s identified actions to the Adverse Events Committee and obtain assurance that they are followed up.

    Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 March 2015.

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

Report the review’s identified actions to the Adverse Events Committee and obtain assurance that they are followed up.

Verbatim wording from the response

“As indicated in the Investigation Report there is to be a review of the system by the Switchboard Management Team. These matters will be reported to our Adverse Events Committee which requires assurance that actions identified in such Trust Reports are followed up and I can confirm that this will occur here.”

Source location

2015-0078-Response-by-University-Hospitals-of-Leicester-NHS-Trust
Page 2 · response
Published 4 March 2015

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026