Recurring concern

Insufficient safe staffing and senior cover out of hours

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First reported 26 Nov 2013•Latest report 26 May 2026

Definition

What this concern includes

Includes recurring deficiencies in staffing capacity, experienced staff availability, senior clinical review, or ward management cover that specifically undermine safe weekend or out-of-hours care.

Not included

  • Excludes staffing or leadership deficiencies not materially connected to weekend or out-of-hours safe care.
  • Excludes failures of diagnostic, referral, documentation, audit or communication processes unless the report directly identifies inadequate weekend staffing or senior cover as the unsafe condition.
  • Excludes generic workforce shortages where no specific safe-care or senior-cover consequence is supported.
Reports
44

Distinct published reports

Individual concerns
48

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
53

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care10
NHS England4
University Hospitals Birmingham NHS Foundation Trust3
University Hospitals Sussex NHS Foundation Trust3
Isle of Wight NHS Trust2
Royal Stoke University Hospital2
Adullam Homes Housing Association Limited1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham Prison1
Blackpool Teaching Hospitals NHS Foundation Trust1
Bournemouth Churches Housing Association Limited1
Care Quality Commission1
Cumbria Health Limited1

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.

  1. Manchester South

    AI-generated summary

    Celia Sanderson · 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

    Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

    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

    Delays in Emergency Department senior clinician review due to insufficient senior medical staffing

    Wider context from the report

    “2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors. Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced. Historically that had been a quieter period however demands on ED meant that was no longer the case. As a consequence senior reviews of patients were further delayed. An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate; ”

    Source location

    Celia Sanderson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.

    Verbatim wording from the response

    “Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.

    Verbatim wording from the response

    “In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 24 February 2023

    Open published response

  2. Manchester North

    AI-generated summary

    Rowan Louis Thompson · 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

    Rowan Louis Thompson was a detained patient at the Gardner Unit who was found in his room on 3 October 2020, thought to be having a seizure, and died shortly after arriving at hospital. The investigation and inquest identified severe hypokalaemia, failures to communicate blood test results, missed and falsified observation records, inadequate emergency response arrangements, and concerns about staffing and auditing.

    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

    Absence of deputy or ward manager cover at weekends

    Wider context from the report

    “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit. ”

    Source location

    Rowan Louis Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit

    Wider context from the report

    “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit. ”

    Source location

    Rowan Louis Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing staffing reviews, weekend briefings and escalation systems are considered sufficient to identify and address changing clinical and staffing needs.

    Verbatim wording from the response

    “Staffing requirements for the Gardener Unit are determined both by the number of ward based nursing staff required to undertake planned tasks and duties during each shift (clinical care, administration of medication, liaison with other professionals and security/environmental requirements for example) and by the individual clinical and risk needs of the young people resident on the ward at that time. Staffing numbers and skill mix are therefore dynamic and can fluctuate on a shift-by-shift basis requiring close oversight of staffing to ensure that the needs of the young people are met safely, and that staff are supported to provide effective care.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 18 October 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    It is not possible to have a deputy ward manager working every shift at the Gardener Unit and other wards.

    Verbatim wording from the response

    “The Gardener Unit has one Ward Manager and three Deputy Ward Managers in its establishment; while Ward Managers do not typically work weekends, Deputy Ward Managers do work shifts across the full week (including nights) but it is not possible to have a Deputy Ward Manager working every shift at the Gardener Unit (and other wards). Weekends are often viewed by the young people as an opportunity for more relaxed and individual time (different to attending planned College lessons or sessions with an MDT member during the week for example) but other activities and sessions do still take place supported by the nursing team and these also include planned visits and social type activities on the ward.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 3 · response
    Published 18 October 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.

    Verbatim wording from the response

    “We understand you have also addressed this Report to Greater Manchester Mental Health NHS Foundation Trust. They will address specifics as to the changes being implemented on the ground.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 18 October 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Trust disputes that staff experience and skill mix were inadequate during the relevant weekend, stating no concerns had been identified.

    Verbatim wording from the response

    “Staffing at the Gardener Unit – as is the case for all other wards within CAMHS – is continually monitored by local managers with review and approval processes in place at the time each staff rota is produced and proactively, and on a rolling basis, to ensure that each individual shift is fully staffed and takes into account any changes that may have occurred at ward level since the staff rotas were first prepared e.g. a change in observations. Briefing meetings occur in advance of every weekend to review staffing requirements for the full weekend and provide the opportunity for local managers to make any required changes.”

    Source location

    Response from Greater Manchester Mental Health NHS Foundation Trust
    Page 2 · response
    Published 18 October 2023

    Open published response

  3. Manchester South

    AI-generated summary

    Ernest Bacon · 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

    Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.

    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

    Insufficient availability of doctors for ward clinical reviews

    Wider context from the report

    “1. The Inquest heard that when Mr Bacon became unwell on 16th January the Trust was staffed at weekend/OOD doctor numbers. This meant that there were a very limited number of doctors available within the hospital when the ward staff asked for a clinical review when Mr Bacon triggered for sepsis on the NEWS2 system. The Inquest heard that the staffing numbers of doctors and reliance on junior doctors at weekend to cover the wards is part of the national staffing model; ”

    Source location

    Ernest Bacon · 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

    Commission NHS England to develop a 15-year NHS workforce plan addressing staffing numbers, skills, supply gaps and retention.

    Verbatim wording from the response

    “With regard to concerns regarding the NHS workforce, the Department has commissioned NHS England to develop a long-term plan for the NHS workforce for the next 15 years. This high-level long-term workforce plan will look at the mix and number of staff required across all parts of the country and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 September 2022

    Open published response

    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

    Fund 1,500 additional annual medical school places for domestic students in England, completing the expansion in September 2020.

    Verbatim wording from the response

    “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 September 2022

    Open published response

    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

    Temporarily lift the cap on English medical school places for eligible students with 2020 or 2021 A-Level offers.

    Verbatim wording from the response

    “In addition, the Government has funded 1,500 more medical school places each year for domestic students in England, which is a 25% increase over three years. This expansion was completed in September 2020 and has delivered over three new medical schools in England. We have seen the first graduates from this expansion enter foundation training in August 2022. Additionally, the Government temporarily lifted the cap on medical school places for students who completed A-Levels in 2020 and in 2021 and who had an offer from a university in”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 30 September 2022

    Open published response

    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

    Publish a workforce plan containing independently verified 10- and 15-year forecasts for doctors, nurses and other professionals.

    Verbatim wording from the response

    “Finally, the Government has committed to publishing the workforce plan next year and this will include independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in future, for 10- and 15-years’ time, taking full account of improvements in retention and productivity. This plan will help ensure that we have the right numbers of staff, with the right skills to transform and deliver high quality services fit for the future.”

    Source location

    Response from Department of Health and Social Care
    Page 3 · response
    Published 30 September 2022

    Open published response

    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

    Progress a business case to increase junior-doctor provision and reduce reliance on locum and agency doctors.

    Verbatim wording from the response

    “Whilst the Trust does acknowledge that the junior doctor rota meets national guidance it does need to be strengthened further to support increased activity and acuity in the ward areas. The Trust is currently progressing a business case to increase the level of junior doctor provision which also aims to reduce reliance on locum and agency doctors.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 1 · response
    Published 30 September 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Overnight junior doctor cover exceeded Royal College of Physicians national guidance when the deterioration occurred.

    Verbatim wording from the response

    “On Sunday night 16th / 17th January 2022, the night when Mr. Bacon’s condition sadly deteriorated, the level of junior doctor cover for the medical wards overnight exceeded that set out in national guidance by the Royal College of Physicians (2018). The actual number of doctors on call at that time were three Tier 1 doctors and one Tier 2 doctor covering non-covid medical beds. At the time that Mr. Bacon died the Trust were experiencing a significant increase in clinical activity as they were responding to the Omicron Covid wave.”

    Source location

    Response from Tameside and Glossop Integrated Care
    Page 1 · response
    Published 30 September 2022

    Open published response

  4. Manchester South

    AI-generated summary

    Margaret Ena Warwick · 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

    Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.

    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

    Insufficient cardiology capacity and out-of-hours cover for timely assessment

    Wider context from the report

    “1. The Inquest heard that under the NICE guidance where a patient needs an operation for a hip fracture such as in Mrs Warwick’s case and needs optimising, that optimisation should be dealt with expeditiously. In Mrs Warwick’s case she needed cardiology assessment. That delay was due in part to a shortage of cardiologists at the trust exacerbated in particular by a lack of cover by cardiologists over weekends and OOH. The Inquest heard that there was no facility for a patient such as Mrs Warwick to be assessed by cardiology over the weekend; ”

    Source location

    Margaret Ena Warwick · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Nottinghamshire

    AI-generated summary

    Jade Michelle Hart · 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

    Jade Michelle Hart died on 9 July 2018 after giving birth, following a uterine inversion caused by inappropriate management of the third stage of labour. She suffered massive uterine haemorrhage and multiple cardiac arrests, with delayed recognition and management of the bleeding, and the inquest concluded that her death was contributed to by neglect. The report raised concerns about the Trust’s serious incident investigation and insufficient support for newly appointed obstetric consultants.

    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

    Insufficient mentoring and out-of-hours senior support for newly appointed Obstetric Consultants

    Wider context from the report

    “2. Insufficient support for newly appointed Obstetric Consultants. The Obstetric Consultant who was on call when Jade died, was newly appointed. She was dealing with an extremely complex and challenging situation, yet did not call for help at an early point, when Jade had had a prolonged cardiac arrest, following the uterine inversion. Whilst I accept that it is unrealistic to expect there to be a second Consultant on call every night or weekend to provide additional support, there does need to be a robust system of mentoring, and access to a senior consultant for prompt advice out of hours for at least one year post consultant appointment, and beyond, when serious emergencies such as this arise. ”

    Source location

    Jade Michelle Hart · 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

    Operate cross-site consultant support, with an on-call obstetric consultant available at each maternity site and reciprocal advice and assistance.

    Verbatim wording from the response

    “We accept that support for staff working at any level in the Trust will be required at times and this applies to the consultants we employ, at any stage after their appointment. We have two main receiving sites in the Trust and run two integrated services with linked, but separately staffed, maternity services at Doncaster Royal Infirmary and at Bassetlaw Hospital in Worksop. Each site has a consultant obstetrician available 24 hours a day. It is now embedded in obstetric practice that when a consultant on call on either site requires advice and support, they will contact the on-call consultant on the other site. This is normally to discuss a patient and is often for ethical advice over a hysterectomy in a young woman, as in this case.”

    Source location

    Response from NHS Doncaster and Bassetlaw Teaching Hospitals
    Page 6 · response
    Published 28 September 2022

    Open published response

  6. Manchester South

    AI-generated summary

    Margaret Kinsey · 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

    Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.

    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

    Insufficient senior emergency department doctor staffing at night

    Wider context from the report

    “1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced. As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care. ”

    Source location

    Margaret Kinsey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester North

    AI-generated summary

    Liam Kenyon · 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

    Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.

    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

    Insufficient weekend staffing capacity to cover all sites and conduct hourly checks

    Wider context from the report

    “6. The Court heard that at a weekend there are less staff to cover all the sites and on the 18th July the staff were dealing with a number of incidents involving residents, meaning to conduct hourly checks would have been difficult. However no member of staff escalated to the on call manager the fact that there were problems. ”

    Source location

    Liam Kenyon · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Blackpool and the Fylde

    AI-generated summary

    Matthew James Rogers · 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

    Matthew James Rogers, aged 31, was admitted to hospital with worsening pain, weakness and lethargy and subsequently developed multiple organ injury before dying on 11 July 2019. His observations were not recorded for two and a half hours despite a NEWS score above 5, amid staffing levels below the planned establishment. The investigation report did not explain how the Trust intended to address omissions of care arising from understaffing.

    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

    Insufficient nurse staffing for the night shift

    Wider context from the report

    “The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department. It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses. The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing. ”

    Source location

    Matthew James Rogers · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Brighton and Hove

    AI-generated summary

    Ioannis AVGOUSTI · 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

    Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

    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

    Insufficient nursing and medical staffing capacity

    Wider context from the report

    “(3) On the same night the nurses and the doctors were working 12½ hour “weekend” shifts”. The day nursing shift was one nurse short and so far as the doctors were concerned they were, as I understand they always are at weekends, too few in number and as a result all staff in hospital are thoroughly stretched and stressed and under resourced. This is no way to run a hospital service. Exacerbating factors in Mr. Avgousti’s case were that his rapid deterioration took place at around handover for both doctors and nurses, thus adding even more pressure to the situation. ”

    Source location

    Ioannis AVGOUSTI · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Plymouth, Torbay and South Devon

    AI-generated summary

    Terence Douglas Thornton · 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

    Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

    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

    Lack of medical cover at the community hospital during out-of-hours admissions

    Wider context from the report

    “BRIEF SUMMARY OF MATTERS OF CONCERN (1) During the course of the Inquest, I heard evidence from ████████ at Liskeard community hospital. She gave evidence that when Mr Thornton was admitted from Derriford, he arrived without an E-discharge, a copy of his prescription chart or his prescribed medication. As he was admitted during a Sunday evening where there was no medical cover in the hospital, this created very real difficulties. The out of hours service had to be contacted for a doctor to attend. In the event, that Doctor refused to prescribe blood thinning medication and Mr Thornton did not receive any for nearly 24 hours notwithstanding his known history of DVTs. ████████ told me that this “happens frequently.” (2) I also heard from Doctor Sant. He works in Liskeard hospital on Mondays and Fridays. On Mondays, he deals with patients who have had been admitted from Derriford over the course of the weekend. He told me in evidence that his “guess” was that between 5 – 10% of patients do not arrive with the correct paperwork or medication. He agreed with my suggestion that if this was allowed to continue it would inevitably result in the future with a patient suffering harm. (3) I would be grateful if you would consider the process for discharging patients from Derriford to Liskeard community hospital particularly where that discharge occurs out of hours, on a Friday (before the weekend) or over the course of a weekend. You may feel that there is a need to ensure the process is more robust and that patients are not discharged without any of the e-discharge form, a copy of the prescription chart and any prescribed medication. You may feel that it would be sensible to audit compliance with these requirements to ensure that an efficient and effective discharge to a community hospital takes place. ”

    Source location

    Terence Douglas Thornton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026