Recurring concern

Failure to escalate staffing shortages through the appropriate management pathway

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First reported 13 Jan 2014•Latest report 3 Apr 2024

Definition

What this concern includes

Includes failures to escalate identified staffing shortages, unavailable staff, or unsuccessful replacement efforts through the designated management or clinical escalation pathway.

Not included

Excludes general staff shortages where no escalation-process deficiency is identified.
Excludes failures to escalate clinical, operational, or welfare problems unrelated to staffing capacity.
Excludes inadequate staffing itself when the report does not identify a failure of escalation.

Reports: 4
Individual concerns: 4
Date range: 2014–2024
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Sheffield Health Partnership University NHS Foundation Trust1

Sherwood Forest Hospitals NHS Foundation Trust1

Stockport NHS Foundation Trust1

Tameside General Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

3 Apr2024
Nottinghamshire
Concerns raised1
1. Failure to escalate insufficient paediatric nursing capacity to senior nursing staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide a 24-hour supervisory Band 7 Nurse in Charge role responsible for staffing allocation and escalation of workforce concerns.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
AI-generated summary

Meha Carneiro · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Meha Carneiro, aged five years and seven months, died at Kings Mill Hospital on 5 December 2022 after collapsing in cardiac arrest following an illness involving fever, cough, abdominal pain, diarrhoea and vomiting. The report identified concerns about insufficient trained paediatric nursing staff, inadequate recognition of the seriousness of her condition, insufficient senior review, and ineffective handover and documentation between staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate insufficient paediatric nursing capacity to senior nursing staff
Wider context from the report
“1. There were insufficient trained Paediatric nurses on duty in the Emergency Department (ED), on the day of Meha’s admission, and there was no effective escalation to senior nursing staff to highlight this ”
Source location
Meha Carneiro · Prevention of Future Deaths report
Page 2 · concerns
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
Provide a 24-hour supervisory Band 7 Nurse in Charge role responsible for staffing allocation and escalation of workforce concerns.

Verbatim wording from the response
“It is not possible to predict sickness and short-term unplanned absence therefore changes to staffing availability may need to be escalated and acted upon at short notice. At the time of Meha’s attendance, the band 7 leads were rostered on day shifts only and included within the ED staffing figures. A new band 7 supervisory Nurse in Charge (NIC) role has been implemented within ED to ensure there is now visible senior support available 24 hours a day for the entire department. At present, the NIC is included within staffing figures, however from July 2024 this role will be supernumerary.”

Source location
Response from Sherwood Forest Hsopitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
Open published response
27 Aug2015
Manchester South
Concerns raised1
1. Failure to understand or implement staff-shortage escalation procedures
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Frederick Sutton · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to understand or implement staff-shortage escalation procedures
Wider context from the report
“(2) Whilst there is a procedure for escalation of the shortage of staff, this was either not fully understood or not properly put into effect. ”
Source location
Frederick Sutton · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jan2014
South Yorkshire (Western)
Concerns raised1
1. Failure to escalate unsuccessful staffing replacement efforts to senior management
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Pamela Margaret Bailey · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Pamela Margaret Bailey left Hawthorn Ward, Northern General Hospital, on 23 March 2013 and was later found deceased at a secluded location near Ladybower, Derbyshire, on 29 March 2013. The medical cause of death was hypothermia. The substantive concerns included ward door security, staffing levels, and the absence of a photograph available to police when she disappeared.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate unsuccessful staffing replacement efforts to senior management
Wider context from the report
“(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place. ”
Source location
Pamela Margaret Bailey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Jan2014
Manchester South
Concerns raised1
1. Failure to escalate staffing shortages to the Night Nurse Practitioner
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Barbara White · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate staffing shortages to the Night Nurse Practitioner
Wider context from the report
“3. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxiliary nurse who was not familiar with the Surgical Unit. This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse Practitioner. ”
Source location
Barbara White · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to escalate insufficient paediatric nursing capacity to senior nursing staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to understand or implement staff-shortage escalation procedures

Concerns raised1

Failure to escalate unsuccessful staffing replacement efforts to senior management

Concerns raised1

Failure to escalate staffing shortages to the Night Nurse Practitioner

Actions described in response 1