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recurance

Delayed emergency response due to unclear call protocol

Closely relatedConfidence 0.85 · high2 reports · 2022–2024 One-page brief (print or PDF)

Nottinghamshire Healthcare NHS Foundation Trust received 2 coroners' reports about this hazard between 19 Jan 2022 and 5 Jan 2024.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 4 specific actions.

2
reports
2
different coroners
2022–2024
years
0.85
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Michelle Whitehead↗

    19 Jan 2022 · Elizabeth Didcock · Nottinghamshire

    “Delayed recognition of Mrs [name redacted] declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in”
    Original on judiciary.uk ↗

    Nottinghamshire Healthcare NHS Foundation Trust responded, stating 3 specific actions.Response (PDF) ↗

    “the Directorate has re-printed new refreshed supplies of the credit card sized NEWS2 quick reference guides (Appendix 1), which identify the physical health parameters and trigger points for escalation to local medical colleagues or the emergency ambulance service. The card is to be wom on a lanyard alongside individual identification badges, acting as an immediate within Adult Mental Health Services and have been shared with the other directorates to ensure consistency across sites.”

    Stated timescale: mid-April 2022

    “Additionally, the Division is rolling out handheld devices that allow staff to immediately enter automatically calculate the NEWS2 scores and alert if interventions or emergency care is required. Confirmation has been received that these have been made available and are in use on all Adult Wade Unit”

    Stated timescale: by end of May 2022

    1 more stated action in the Promises tab.

  2. 2 years later

    Raised again · 1st time

    Tammy Watkins↗

    5 Jan 2024 · Laurinda Bower · Nottingham and Nottinghamshire

    Closely relatedConfidence 0.85 · higha different coroner
    “There was significant confusion in this case as to who should call a medical emergency and how information should be relayed to the ambulance service.”
    Original on judiciary.uk ↗

    Nottinghamshire Healthcare NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗

    “The Trust have recognised the need to fully review how and what physical healthcare is offered across all inpatient services and successfully recruited an Associated Director of Physical Healthcare last year. This is a strategic post and covers all three care groups. Their initial priority has been to scope all physical health models of care across inpatient services with the aim of understanding the unique needs of patients across our services. The next phase will look to address the associated”

    Stated timescale: next 12 months

  3. All reports to Nottinghamshire Healthcare NHS Foundation Trust

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error