Andrew Guillaume
29 Dec 2023 · Coroner Deborah Lakin · Coventry and Warwickshire
The coroner's concerns
1. inability to contact UHCW switchboard
“The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions”
2. missed multidisciplinary meeting
“Mr [name redacted] was not discussed at the Multi-Disciplinary Team meeting with UHCW on 9 June 2023, as the referral had not been completed”
3. delayed patient transfer
“Had the referral been completed, the team at UHCW could have prioritised the patient's transfer”
Responses
2023-0549-Response-from-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
2023-0549-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“We welcome the report's action plan which, in addition to the joint review references above, includes a review of UHCW referral mechanisms and circulation of a Trust-wide Safety Practice Alert with the priority telephone number for UHCW referrals.”
2023-0549-Response-from-South-Warwickshire-University-NHS-Foundation-Trust.pdf ↗· South Warwickshire University NHS Foundation Trust
2023-0549-Response-from-University-Hospitals-Conventry-and-Warwickshire-NHS-Trust.pdf ↗· University Hospitals Coventry and Warwickshire NHS Trust