“The inability of Medical Consultants and staff to get through to the switchboard at UHCW…”
Dated 29 Dec 2023, from the coroner for Coventry and Warwickshire. Sent to 4 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 23 Feb 2024.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated29 Dec 2023
- Deadline23 Feb 2024
- Published on judiciary.uk3 Jan 2024
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| South Warwickshire University NHS Foundation Trust | Response publishedPublished on judiciary.uk in January 2024. |
| University Hospitals Coventry and Warwickshire NHS Trust | Response publishedPublished on judiciary.uk in January 2024. |
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in January 2024. |
| NHS England | Response publishedPublished on judiciary.uk in January 2024. |
The coroner’s concerns
– (1) The inability of Medical Consultants and staff to get through to the switchboard at UHCW on two occasions. (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. (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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2023-0549
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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