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. Nottinghamshire

    AI-generated summary

    Olive Wilmott · 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

    Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.

    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 overnight staffing for dementia unit residents’ needs

    Wider context from the report

    “2. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents’ needs (one staff member dedicated per floor of the dementia unit during the night shift). ”

    Source location

    Olive Wilmott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Nadim Muzzfar BUTT · 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

    Nadim Muzzfar BUTT died on 5 September 2014 after complications following laparoscopic gastric bypass surgery, including small bowel obstruction, systemic inflammatory response syndrome and multi-organ failure. The report raised concerns that the hospital review was not escalated to a serious untoward incident or root cause analysis, and that no consultant-led out-of-hours on-call rota was in place for postoperative patients.

    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 a consultant-led out-of-hours on-call rota for postoperative patients

    Wider context from the report

    “2. Despite the recognition that a consultant-led out of hours on-call rota is required for patients having undergone surgery, no such rota is yet in place. ”

    Source location

    Nadim Muzzfar BUTT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Clifford Irwin Crofts · 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

    Clifford Irwin Crofts, who had Parkinson’s disease and aspiration difficulties, was admitted to hospital and underwent insertion of a radiologically inserted gastrostomy tube on 19 September 2014. He experienced acute pain after feeding began, but there were delays in escalating his care, obtaining a CT scan and carrying out surgery; he subsequently developed respiratory difficulties and died on 10 October 2014. The substantive concerns included failure to follow the RIG care plan, difficulties escalating care, delays in obtaining urgent CT imaging, and weekend 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

    Insufficient numbers of doctors at all levels of seniority available at weekends

    Wider context from the report

    “(4)During the course of evidence it became clear that the delay in attempts to escalate Mr Crofts’ care over the weekend was due in large part to staffing levels. Whilst I heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E. ”

    Source location

    Clifford Irwin Crofts · 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 an additional doctor on the emergency medical take from 16:00 to 23:00 every day through adjusted junior-doctor rotas.

    Verbatim wording from the response

    “• We have recently adjusted the medical junior doctor rotas such that there is an extra doctor on the emergency medical take from 16:00 to 23:00 every day.”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 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

    Define minimum safe medical staffing levels for each clinical area and doctor grade through a Medical Director-led workstream.

    Verbatim wording from the response

    “• In contrast to nursing practice, there is no guidance as to what constitutes ‘safe staffing’ for doctors. This is an issue we are trying to address at Ashford and St Peter’s and the Medical Director is leading a work-stream which is attempting to define, for each clinical area and each grade of doctor, the safe minimal level of medical staffing.”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 2016

    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

    Current contractual restrictions limit the ability to roster doctors for elective work during premium time, constraining implementation of identified safe staffing levels.

    Verbatim wording from the response

    “It is likely the implementation of identified safe staffing levels for doctors will require the introduction of the new contracts for both junior doctors and consultants as at present there are significant restrictions on our ability to roster doctors to perform elective work within ‘premium time’ (19:00 to 07:00 weekdays and any time at weekends).”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 2016

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · 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

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    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 night-time staffing for residents requiring assistance from two carers

    Wider context from the report

    “8. That the night time provision of two staff members to cover the main Lodge and two to cover the Horton Suite (two separate but joined buildings) was not seen as a minimum requirement to ensure the health and safety of residents when at least one resident in each building needed the assistance of two carers, but that only three were regularly rostered for the night shift. ”

    Source location

    Elsie Marjorie Brown · 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

    Clarify Horton Suite admission criteria to restrict admission to reasonably independent, low-falls-risk residents.

    Verbatim wording from the response

    “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    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

    Provide a minimum of four staff across the building when a Horton Suite resident requires support from two carers.

    Verbatim wording from the response

    “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    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

    Four night staff were not considered routinely necessary because the two areas formed one linked building and staffing levels were based on residents’ dependency.

    Verbatim wording from the response

    “Langwith Lodge Residential Home has two named areas but is one building and everything in the main ‘Lodge’ is linked with the ‘Horton Suite’. All the systems that make the home safe, such as fire alarms and the ‘carer assist system’, (colloquially called ‘nurse call’), work equally in all areas of the home and are linked together, so staff across the building know when someone requires assistance. The Horton suite is accessible both at the front and rear of the main lodge through internal doors. We have the two identified areas to distinguish between the ‘traditional care home’ and the Horton suite which is marketed to more independent residents. Dependency checks are completed for all residents to support safe staffing numbers.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    Open published response

  5. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 provide senior clinical review

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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

    Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    Open published response

  6. Nottinghamshire

    AI-generated summary

    Mrs Elizabeth Ann Cox · 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 Elizabeth Ann Cox, who was 84 and had a high risk of falls, fell from her hospital bed on 18 July 2014 after the equipment accepted as necessary—a Hi-Lo bed and crash mats—had not been provided. Her condition deteriorated and she died at Kingsmill Hospital on 10 August 2014; the report found a clear link between the fall and her death. The report also raised concerns about insufficient night staffing and the lack of equivalent additional staffing support during night 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

    Insufficient overnight ward staffing capacity for patient workloads

    Wider context from the report

    “The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after. We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice. 1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night. 2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads. ”

    Source location

    Mrs Elizabeth Ann Cox · 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

    Unavailability of overnight additional staffing resources

    Wider context from the report

    “The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after. We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice. 1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night. 2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads. ”

    Source location

    Mrs Elizabeth Ann Cox · 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 assessed enhanced one-to-one care day and night using ward, bank or agency staffing when additional resources are required.

    Verbatim wording from the response

    “1. A risk assessment form is completed on the ward identifying the level of enhanced care that is required.”

    Source location

    2015-0094-Response-by-Sherwood-Forest-Hospital
    Page 2 · response
    Published 12 March 2015

    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

    Implement the approved nursing staffing model of five registered and two unregistered staff by day and three registered and one unregistered staff by night.

    Verbatim wording from the response

    “New Investment Numbers: RN Days Numbers: 5 HCA Days Numbers: 2 RN Nights Numbers: 3 HCA Nights Numbers: 1 Overall Numbers: 5+2 Days; 3+1 Nights”

    Source location

    2015-0094-Response-by-Sherwood-Forest-Hospital
    Page 4 · response
    Published 12 March 2015

    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

    Drive a nurse recruitment strategy to recruit the registered nurses required for medical wards to adopt the new staffing model.

    Verbatim wording from the response

    “Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.”

    Source location

    2015-0094-Response-by-Sherwood-Forest-Hospital
    Page 6 · response
    Published 12 March 2015

    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

    Monitor staffing levels and their impact on quality and safety through the Trust Board and Quality Committee.

    Verbatim wording from the response

    “Requests for enhanced care and 1-1 support will continue to be supported when required. During this period of change the Trust Board and the Quality Committee continue to robustly monitor the staffing levels and the impact upon quality and safety.”

    Source location

    2015-0094-Response-by-Sherwood-Forest-Hospital
    Page 6 · response
    Published 12 March 2015

    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

    Medical wards cannot adopt proposed staffing levels until approximately 100 additional registered nurses are recruited, anticipated to take a further 12 months.

    Verbatim wording from the response

    “Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.”

    Source location

    2015-0094-Response-by-Sherwood-Forest-Hospital
    Page 6 · response
    Published 12 March 2015

    Open published response

  7. Manchester South

    AI-generated summary

    Neil Thomas Westerman · 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

    Neil Thomas Westerman attended Stepping Hill Hospital for an elective cholecystectomy on 2 July 2014, after which a bile leak caused septicaemia. Concerns included the pre-operative assessment being conducted by a junior doctor, incomplete operation notes about equipment and materials, and insufficient junior doctors available in practice, particularly at night.

    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 junior doctor staffing to cover patient needs

    Wider context from the report

    “3. I heard evidence, as I have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night. It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available. ”

    Source location

    Neil Thomas Westerman · 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

    Review general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    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

    Increase junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    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

    Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    Open published response

  8. Staffordshire South

    AI-generated summary

    Peter Jonathan Wright · 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

    Peter Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

    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 out-of-hours doctor cover at the hospital

    Wider context from the report

    “(2) At the time of this incident there was still a 24 hour Emergency Department at the nearby Stafford Hospital and at St George’s Hospital there was no doctor on site. Now the Emergency Department at County (formerly Stafford) Hospital is not open during the night and the nearest ED is at Stoke. I was told that the situation can be managed by calling paramedics. While I appreciate that nearly all the doctors at St George’s are psychiatrists not medics I wonder if any consideration has been given to out of hours cover by a doctor? ”

    Source location

    Peter Jonathan Wright · Prevention of Future Deaths report
    Page 1 · 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

    Non-resident medical cover, trained staff, emergency equipment, basic life support and 999 access are considered sufficient for out-of-hours medical emergencies.

    Verbatim wording from the response

    “The Trust does not have resident doctors on call but operates a non-resident out of hour’s rota to comply with European Working Time Directive.”

    Source location

    2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
    Page 2 · response
    Published 2 March 2015

    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

    Paramedics are considered best placed to provide advanced emergency support and stabilisation before transfer to hospital.

    Verbatim wording from the response

    “Every clinical and non-clinical area has first aid in place and wards are stocked with equipment for managing common emergencies. We do however recognise that more sophisticated medical equipment and support may be required at times, and in the case of a medical emergency we expect staff to call 999 without delay, as this is what people in the community would do in similar circumstances.”

    Source location

    2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
    Page 2 · response
    Published 2 March 2015

    Open published response

  9. Birmingham and Solihull

    AI-generated summary

    Yohannes Kidane · 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

    Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.

    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 night staffing to enable staff comfort breaks

    Wider context from the report

    “(3) When I asked how staff took breaks at night I was told staff did not take breaks during the night. I am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels. ”

    Source location

    Yohannes Kidane · Prevention of Future Deaths report
    Page 1 · 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

    Insufficient night staffing to provide healthcare and other prisoner needs

    Wider context from the report

    “(1) The healthcare department has 2 wards with 15 patients on each ward. The evidence presented at the inquest confirmed that at night the healthcare wards are staffed by 1 nurse per ward and 1 prison officer who is shared between both wards. Evidence confirmed there were a number of prisoners on ward 2 who required ACCT observation plus other prisoners requiring attention. At the time only 1 nurse was present as the Prison officer was on the other ward. I am concerned the wards have insufficient staff at night to provide for all the healthcare and other needs of prisoners. ”

    Source location

    Yohannes Kidane · 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

    Liaise with Birmingham Community Healthcare Trust and G4S regarding night staffing levels and additional overnight support.

    Verbatim wording from the response

    “In order to respond to the concerns that you have raised, the Trust has liaised with Birmingham Community Healthcare Trust (who provide physical healthcare on Ward 1 of the healthcare centre) and G4S who provide healthcare prison officers in the”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 1 · response
    Published 3 September 2014

    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

    Continue pursuing Commissioner funding for an additional Ward 2 staff member.

    Verbatim wording from the response

    “I am disappointed to report that we asked our Commissioner to attend two meetings regarding funding of an extra staff member for Ward 2. They declined to attend”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 3 · response
    Published 3 September 2014

    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

    Existing night staffing and break-cover arrangements are considered sufficient, with additional staff available for high ACCT numbers or continuous supervision.

    Verbatim wording from the response

    “Staff breaks at night The Night Orderly Officer arranges cover for breaks with the staff on duty at the beginning of each night shift. If there is a particularly high number of prisoners subject to Assessment, Care in Custody and Teamwork (ACCT) process in one location, the Night Orderly Officer may choose to locate an additional member of staff in that area. This is not common practice as night staffing levels are assessed as sufficient, but it is an option that can be used. If there”

    Source location

    2014-0392-Response-by-NOMS
    Page 1 · response
    Published 3 September 2014

    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

    Funding approval for an extra Ward 2 staff member has not progressed because the Commissioner declined meetings; the matter will continue to be pursued.

    Verbatim wording from the response

    “I am disappointed to report that we asked our Commissioner to attend two meetings regarding funding of an extra staff member for Ward 2. They declined to attend”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 3 · response
    Published 3 September 2014

    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

    Healthcare Commissioners are responsible for funding additional prison healthcare staff and are invited to address the staffing concern.

    Verbatim wording from the response

    “healthcare centre. The Trust has also forwarded a copy of your letter to the Commissioner responsible for funding healthcare services within the prison.”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 2 · response
    Published 3 September 2014

    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 first concern falls within the Mental Health NHS Foundation Trust’s responsibility, and that Trust will respond separately.

    Verbatim wording from the response

    “You have raised three matters of concern. I am aware that the first of which concerns matters for Birmingham and Solihull Mental Health NHS Foundation Trust who will be responding separately. I will therefore address the second and third in turn.”

    Source location

    2014-0392-Response-by-NOMS
    Page 1 · response
    Published 3 September 2014

    Open published response

  10. Central and South East Kent

    AI-generated summary

    Herbert Chandler · 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

    Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

    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 provide consultant on-call respiratory cover

    Wider context from the report

    “A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”

    Source location

    Herbert Chandler · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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