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10 Jun 2019 · Coroner Rachel Knight · South Wales Central

The coroner's concerns

  1. 1. delays and miscommunications in neurosurgical referrals

    “There are a high number of referrals to the single rota'd on-call neurosurgical specialist registrar every day. The system for making and receiving the referrals is not fit for purpose, with inefficient delays, miscommunications and confusion occurring. The use of the UHW switchboard and bleeping the doctor is archaic, and does not utilise technology as it should. Further, if the on-call doctor is in surgery or dealing with an emergency, there is no back up doctor to field the referrals, which”

Responses

2019-0192-Response-by-NHS-Wales.pdf ↗· Cardiff and Vale University Health Board

Stated action · Monday 23rd September 2019

“The current system for urgent and immediate care of patients with Emergency Neurosurgery needs will continue with the referral being made through the bleep system to the on call Neurosurgical Registrar. [name redacted] effect from Monday 23rd September 2019 the referrer will be asked a question to gauge if the call is urgent or routine in nature. The urgency of the call will be communicated to the r Registrar via the bleep system which will enable them to prioritise urgent calls over less urgent tasks. If”
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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.

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