PFD report

Andrew Douglas Guillaume · Prevention of Future Deaths report

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Issued 29 Dec 2023•Coventry and Warwickshire

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
3

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
13

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 raised3

  1. Failure to ensure Cardiology team awareness and access to the emergency GP telephone number
    Part of recurring concern: Unreliable access to emergency communication
  2. Failure to complete referrals needed for UHCW Multi-Disciplinary Team discussion
  3. Failure of Medical Consultants and staff to access the UHCW switchboard
    Part of recurring concern: Unreliable hospital switchboard access and handling of urgent clinical requests
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.5

  1. Action

    Establish a 24-hour, seven-day direct communication escalation process.

    Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
  2. Action

    Share the confirmed escalation arrangement with other providers across the system.

    Stated by University Hospitals Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2024.
  3. Action

    Develop longer-term technological alternatives for accessing clinical teams and making referrals between organisations.

    Stated by South Warwickshire University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 January 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.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 responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to emergency communication.

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 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable hospital switchboard access and handling of urgent clinical requests.

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 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

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

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.8

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
  2. 2

    Share learning and insights from Prevention of Future Deaths reports across NHS national and regional levels.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
  3. 3

    Continue exploring technological and digital communication improvements.

    Stated by University Hospitals Coventry and Warwickshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 January 2024.
  4. 4

    Conduct a tabletop review and learning event with SWUFT to identify process improvements.

    Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
  5. 5

    Share review learning through cardiology governance, Emergency Division audit and operational forums, and the medical staff Grand Round.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.
  6. 6

    Send SWFT staff names for participation in developing the short-term communication process.

    Stated by South Warwickshire University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2024.
  7. 7

    Review how registrar-level staff can build relationships across organisations to improve communication and team working.

    Stated by South Warwickshire University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2024.
  8. 8

    Complete the joint roundtable review of the case with UHCW.

    Stated by South Warwickshire University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Responsibility for providing the Regulation 28 response rests with South Warwickshire University Hospitals NHS Foundation Trust.

    Stated by University Hospitals Coventry and Warwickshire NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
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 learning and insights from Prevention of Future Deaths reports across NHS national and regional levels.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
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

Continue exploring technological and digital communication improvements.

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

Conduct a tabletop review and learning event with SWUFT to identify process improvements.

Verbatim wording from the response

“Thank you for sharing the Regulation 28 report for the above patient. Whilst the Regulation 28 response is required from South Warwickshire University Hospitals (SWUFT) we have engaged with them by way of a tabletop review/learning event, having recognised that there were aspects of our processes that were identified in the report that required improvement.”

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 review learning through cardiology governance, Emergency Division audit and operational forums, and the medical staff Grand Round.

Verbatim wording from the response

“5 | Learning from the review to be shared within cardiology governance meeting and as part of the cardiology specialty report to the Emergency division audit and operational group | Dr Tan, Governance lead to share learning at cardiology governance meeting and at the Emergency division audit and operational group Case to be presented by the cardiology team at Grand Round | Dr Y Tan | 31/10/2023 | Action completed 12 January 2024”

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

Send SWFT staff names for participation in developing the short-term communication process.

Verbatim wording from the response

“b. Short-term Communication Pathways ii. Whilst long-term solutions are being developed, SWFT/UHCW to develop short term process for:”

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

Review how registrar-level staff can build relationships across organisations to improve communication and team working.

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

Complete the joint roundtable review of the case with UHCW.

Verbatim wording from the response

“Following receipt of your Regulation 28 Report, the Trust arranged a meeting between senior staff and managers from UHCW and SWFT who it was felt could contribute to the points you raised. Attendees at the meeting included SWFT’s Chief Nursing Officer, Associate Chief Medical Officer for Governance, Consultants and General Managers for relevant specialities and UHCW’s Group Director of Nursing, Associate Director of Nursing, Quality and Patient Safety Lead, and Deputy Chief Medical Officers. The Group discussed a number of issues highlighted by Mr Guillaume’s case and also carefully considered the adequacy of the actions that had been jointly identified by the two organisations as part of the Serious Incident investigation that was referred to at the inquest.”

Source location

Response from South Warwickshire University NHS Foundation Trust
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 providing the Regulation 28 response rests with South Warwickshire University Hospitals NHS Foundation Trust.

Verbatim wording from the response

“Thank you for sharing the Regulation 28 report for the above patient. Whilst the Regulation 28 response is required from South Warwickshire University Hospitals (SWUFT) we have engaged with them by way of a tabletop review/learning event, having recognised that there were aspects of our processes that were identified in the report that required improvement.”

Source location

Response from University Hospitals Conventry and Warwickshire NHS Trust
Page 1 · response
Published 3 January 2024

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