Recurring concern

Insufficient safe staffing and senior cover out of hours

First to latest report 26 Nov 2013 — 26 May 2026

Reports that mention this concern
44
Times this concern has been raised
48
Stated actions linked to this concern
53

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.

What is 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 and published responses 44 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Birmingham and Solihull

    AI-generated summary

    Ann Swoffer · 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

    Ann Swoffer died on 02/09/18 after an oesophageal perforation developed following dilatation during naso-jejunal tube insertion. The report identified concerns about the procedure being contrary to accepted practice, delayed recognition and treatment of the perforation, inadequate escalation to senior staff at the weekend, and inconsistent practices and protocols across hospital sites.

    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

    Unavailability of senior staff in the hospital during weekend care

    Wider context from the report

    “2. The deceased deteriorated as a result of a late perforation over the August Bank Holiday weekend. Junior staff did not identify the problem and did not escalate this to senior staff. I was told a “work force issue” meant senior staff were not present in the hospital at the time. Patients who become ill at the weekend need to receive the same standard of care as in the week. Consideration needs to be given to how this can be addressed. ”

    Source location

    Ann Swoffer · Prevention of Future Deaths report
    Page 1 · 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

    Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.

    Verbatim wording from the response

    “At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.”

    Source location

    2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
    Page 3 · response
    Published 23 May 2019

    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

    A consultant was available on call and an upper gastrointestinal consultant was on site, contrary to the concern that senior staff were absent.

    Verbatim wording from the response

    “At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.”

    Source location

    2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
    Page 3 · response
    Published 23 May 2019

    Open published response

  2. Isle of Wight

    AI-generated summary

    Natalie Zara HUNTER · 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

    Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.

    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 out-of-hours mental health/Crisis staffing

    Wider context from the report

    “5. During the course of the live evidence I heard from ████████, Service Manager for Community Mental Health Services at the Isle of Wight NHS Trust, in connection with the lack of sufficient numbers of out-of-hours mental health or Crisis staff which are available across the Isle of Wight. His evidence (which has since been supplemented by up-to-date figures), was that the team currently comprises of 11.1 full-time equivalent Band 6 mental health staff members, but it really requires 15.74 full-time equivalent appropriately qualified staff members which would necessitate 4.64 full-time equivalent additional staff to be funded and recruited in order to be able to offer a full and effective service. 6. The evidence was that there are currently insufficient funds in order for a full complement of out-of-hours mental health/Crisis staff to be deployed which is affecting the way in which the Mental Health service operates and delivers care to those who need it out-of-hours. 7. Accordingly, I have concerns that those who are vulnerable with mental health issues and who need to be seen out-of-hours are currently not in receipt of an adequately staffed out-of-hours mental health provision. ”

    Source location

    Natalie Zara HUNTER · Prevention of Future Deaths report
    Page 3 · 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

    Fill staffing vacancies with bank and agency cover to provide a 24-hour site-based service.

    Verbatim wording from the response

    “• All staffing vacancies have been filled with bank and agency cover to ensure there is a 24 hour site based service (not deployable).”

    Source location

    2018-0392-Isle-of-Wight-NHS-Trust
    Page 2 · response
    Published 14 May 2019

    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

    Evaluate the most effective approach to providing safe 24-hour cover.

    Verbatim wording from the response

    “• The service is constantly evaluating the most effective way to provide safe 24hr cover.”

    Source location

    2018-0392-Isle-of-Wight-NHS-Trust
    Page 2 · response
    Published 14 May 2019

    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

    Prepare and secure approval for a business case developed with the CCG and local authority for a revised out-of-hours care model.

    Verbatim wording from the response

    “• A Business case has been prepared in collaboration with the CCG and local authority, and has been signed off by the Mental Health Divisional Board and Quality Committee. This will change the model of care for the single point of access, the community mental health team and result in the creation of a new wellbeing service. The aim of the new model is to improve access, responsiveness and quality of 24/7 service provision.”

    Source location

    2018-0392-Isle-of-Wight-NHS-Trust
    Page 2 · response
    Published 14 May 2019

    Open published response

  3. Berkshire

    AI-generated summary

    Michelle Roach · 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

    Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.

    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 medical registrar cover at night

    Wider context from the report

    “(1) I consider that the trust should review its level of cover by medical registrars at night. Financial constraints and limits on the numbers of medical registrars available to the trust are frequently matters determined outside of the trust’s immediate control, and, as such, these matters may need to be raised outside the trust. ”

    Source location

    Michelle Roach · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Roger Albert Saxby · 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

    Roger Albert Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.

    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 of a vascular hub to maintain required staffing and resources

    Wider context from the report

    “There are basic requirements for staffing and resources for a vascular hub. Royal Sussex County Hospital does not meet these requirements. As a result of this failing it was necessary for Mr Saxby to be transferred to another hub – at inquest I heard that this was an almost unheard of transfer. It is unacceptable that a vascular hub does not meet the basic requirements and provide the basic resources. I heard that measures are ‘in place’ for this situation to be remedied, but in my view that is not good enough. There is no guarantee that in a weeks time another Mr Saxby will not appear on a Friday afternoon or evening and require the full resources that he should receive but find they are not available. Resources may be reduced but that is not an excuse for providing unsafe services. In addition, the decision to transfer Mr Saxby to St George’s was delayed and on arrival at St George’s the start of thrombolysis was also delayed. After Mr Saxby received his thrombolysis at St George’s, it became clear that the discussion about what should happen to him next was completely unstructured. None of those involved in his case demonstrated any sense of urgency. There was insufficient discussion with Mr Saxby. Having had one ‘most unusual’ transfer from hub to hub there was apparently no thought that another ‘most unusual’ transfer from hub to hub might not be in Mr Saxby’s best interest. The essence of the first transfer is to ensure the patient is transferred from spoke to hub speedily so they can receive specialist care in a centre of excellence. There should never need to be a hub to hub transfer and certainly not two of them within 36 hours of each other. ”

    Source location

    Roger Albert Saxby · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Southampton and New Forest

    AI-generated summary

    Owen Richard Widlake · 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

    Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.

    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

    Inadequate out-of-hours NICU staffing levels

    Wider context from the report

    “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff. 2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph. 3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN ii) a lack of empowerment indicating a lack of leadership. 4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves. 5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this. 6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm. 7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover. ”

    Source location

    Owen Richard Widlake · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Worcestershire

    AI-generated summary

    Michael Edward Giles · 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

    Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and medical records.

    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 senior review of patients over weekends

    Wider context from the report

    “(2) The absence of a senior review of patients over the weekend was a factor in the suboptimal care given to this patient. ”

    Source location

    Michael Edward Giles · Prevention of Future Deaths report
    Page 1 · 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

    Reorganize consultant working practices to increase the proportion of patients receiving review at least every 24 hours.

    Verbatim wording from the response

    “There is already an expectation that all patients need to be reviewed 7 days per week. For those patients with high dependency needs the expectation is that they are seen and reviewed by a consultant twice daily (including acutely ill patients directly transferred and other who deteriorate). An audit of our practice from March 2017 shows that we were able to meet this requirement 93% of occasions. The overall proportion of patients who required a daily consultant review and were reviewed by a consultant was 68%. In order to improve this further working practice by consultants has been reorganised to facilitate a higher proportion of patients being seen at least once every 24 hours. In order to keep the risks to a minimum for patients undergoing invasive procedures we are already reviewing where these can be done, i.e.”

    Source location

    2017-0309-Response
    Page 2 · response
    Published 28 November 2017

    Open published response

  7. Manchester North

    AI-generated summary

    Ms Edith Robinson · 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

    Ms Edith Robinson was admitted to Accident and Emergency after a fall, with problems identified with her prosthetic hip. Surgery was delayed and, as she deteriorated, action was not taken to rescue her; she died at Royal Oldham Hospital on 20 June 2016. The report identified concerns about weekend consultant review, early warning score calculation and use, record keeping, escalation, communication and other aspects of care.

    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 Consultant review of patients over weekends

    Wider context from the report

    “1. Consultant Review over Weekends - During the course of the evidence, I heard that patients such as the deceased are not seen or reviewed by a Consultant over the weekend. I am concerned that this gap in care is putting patients at serious risk. The signs and symptoms of life-threatening illnesses (such as sepsis) are not being diagnosed and/or treated appropriately. Diagnosis and treatment is often time critical and requires significant clinical skill and expertise as signs can be subtle. ”

    Source location

    Ms Edith Robinson · Prevention of Future Deaths report
    Page 1 · 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

    Work with the NHS to make seven-day services available in all hospitals.

    Verbatim wording from the response

    “Firstly, on the matter of consultant review over weekends, I can assure you that it is a key commitment of the Government to work with the NHS so that seven day services are available in all hospitals.”

    Source location

    Edith-Robinson-Response
    Page 1 · response
    Published 19 July 2017

    Open published response

  8. West Sussex

    AI-generated summary

    Dennis Allen Teesdale · 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

    Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

    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 assured general surgical competence in out-of-hours cover

    Wider context from the report

    “9. Mr Teesdale was cared for ‘out of hours’ by a trainee oral-maxillo-facial surgeon with unknown general surgical experience who did not recognise or manage the severity of a surgical complication. ”

    Source location

    Dennis Allen Teesdale · 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

    NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.

    Verbatim wording from the response

    “Finally, I am satisfied that the regulators are alert to the risks you have highlighted, and it is for NHS Improvement, NHS England and the Care Quality Commission, working with the Trust and its commissioners, to ensure sufficient and appropriate action is taken to address the concerns raised. My officials have asked to be kept informed of developments.”

    Source location

    2017-0202-Response-by-Department-of-Health
    Page 3 · response
    Published 28 July 2017

    Open published response

  9. East London

    AI-generated summary

    Mrs Catherine Dinnen · 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

    Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

    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

    Inadequate out-of-hours medical staffing

    Wider context from the report

    “2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”

    Source location

    Mrs Catherine Dinnen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester West

    AI-generated summary

    Margaret Mary Gleeson · 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 Mary Gleeson underwent elective incisional hernia repair and sustained a tear to her mesentery, after which her condition deteriorated and she developed sepsis. She suffered a cardiac arrest during further surgery and died on 4 October 2015; concerns included weekend staffing levels and inaccurate or poorly understood use of the MEWS tool.

    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

    Wider context from the report

    “1. At the weekend on the call team had to do the job of 4 teams and that it was not possible to provide patients with the care they deserve. In those circumstances, I consider that staffing levels should be reviewed. ”

    Source location

    Margaret Mary Gleeson · 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 four-hour weekend ward rounds by middle-grade surgeons for elective surgical patients, with concerns reported to on-call consultants.

    Verbatim wording from the response

    “During the inquest evidence was heard that at weekends the surgical on call team were extremely busy which led to patients, on occasions, not always receiving the standard of treatment they should expect. The Directorate of General Surgery recognised the variation in patient care that existed between weekends and weekdays, and action has been taken accordingly.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 1 · response
    Published 15 July 2016

    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

    Recruit two clinical fellows to provide sufficient clinicians for the additional weekend ward rounds.

    Verbatim wording from the response

    “To ensure there are sufficient clinicians to cover the additional ward rounds, the Trust is in the process of recruiting 2 clinical fellows. One appointment has already been made, and it is hopeful the second appointment will be filled in the upcoming weeks.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026