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. Surrey

    AI-generated summary

    Maria De Oliveria Alva LOPES · 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

    Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.

    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 ward rounds in weekend urology on-call arrangements

    Wider context from the report

    “1. The consultant urologist’s on call arrangements covering three hospitals at the weekend has no provision for consultant ward rounds, in contravention of suggested national guidelines ”

    Source location

    Maria De Oliveria Alva LOPES · 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 weekend urology review and supervision through consultant ward rounds, registrar emergency assessments, case discussion and consultant availability.

    Verbatim wording from the response

    “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 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

    Review the three-hospital urology on-call services and develop an action plan toward seven-day compliance.

    Verbatim wording from the response

    “This has set out standards which would mean that all emergency in patients would be assessed by a suitable consultant within six hours, (during periods of consultant presence on an acute ward) and, at other times, must have a thorough clinical assessment by a suitable consultant within 14 hours of arrival in hospital. Implementation of this guidance is over the next three years, with a submission of action plans in 2014/15, implementation of the greatest impact changes in 2015/16 and compliance by 2016/17. These standards represent a paradigm shift from the usual on-call arrangements concerning urology in the majority of hospitals in this country. The three trusts will need to undertake a review of the on-call services to develop an action plan towards becoming compliant with 7-day working.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 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

    No specific national urology on-call guidelines existed; the cited recommendations were recent and not yet fully implemented.

    Verbatim wording from the response

    “There are no current suggested national guidelines concerning the provision of consultant ward rounds but we believe this is a reference to the guidelines produced by Sir Bruce Keogh in a paper presented to NHS England in December 2013, outlining seven days a week service.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 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 weekend arrangements provide registrar and consultant review of urology emergency admissions and inpatients.

    Verbatim wording from the response

    “When the consultant urologists' on-call rota was established covering North Hampshire Hospital, Royal Surrey County Hospital and Frimley Park Hospital, the agreement was that trusts would make their own arrangements for review of in-patients/emergencies at the weekend. I believe that we have robust arrangements at Frimley Park Hospital, with the consultant on-call on Friday night available to see admissions and a Saturday morning ward round by Specialist Registrar or equivalent who reviews all emergency admissions and in-patients. These cases are then discussed with the consultant who had been on-call on the Friday night. A Frimley Park Hospital consultant is available to come to see these patients. The on-call consultant on the rota is then available for advice and we”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 1 · response
    Published 11 July 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 arrangements provide safe, supervised out-of-hours trainee practice through registrar discussions and consultant advice or review when required.

    Verbatim wording from the response

    “2. A general lack of knowledge or implementation of published ‘on-call’ national guidelines As mentioned above, there are no specific on-call guidelines produced nationally for urology and the Keogh recommendations were published within the last year. These have therefore come into force subsequent to Mrs Lopez's tragic death and it is intended that consultants from all three hospitals meet to discuss future arrangements for on-call. The current on-call arrangements at Frimley Park Hospital have operated safely for over ten years and, by discussing cases with the registrar on Saturday and reviewing collaborative decisions made by the registrars the next day, we are able to provide supervision of the registrars. In addition, the on-call consultant for all three hospitals is able to review patients, if requested.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 11 July 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

    Consultant-delivered emergency services with regular inpatient ward rounds require additional consultant appointments before compliance can be achieved.

    Verbatim wording from the response

    “3. The overall supervision of out-of-hours urology trainees within the system The overall supervision of out-of-hours' urology trainees within the current system is specific to the arrangements within each Trust. Trainees have access to consultant advice and review, if necessary, 24/7 during the on-call weekend. Provision of consultant-delivered emergency service with regular in-patient ward rounds will require additional consultant appointments to allow trusts to become compliant with Keogh. There is wide variety of provision of urology cover across the country, with approximately 50% of urology departments dependent on general surgical middle grade support. We are fortunate to have urology middle grade support for our emergencies. It is recognised by BAUS that this is an issue that will need to be addressed in the next couple of years.”

    Source location

    2014-0325-Response-by-Frimley-Park-Hospital
    Page 2 · response
    Published 11 July 2014

    Open published response

  2. Bedfordshire and Luton

    AI-generated summary

    Sari Marlene KEEN · 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

    Sari Marlene KEEN underwent surgery to remove colon tumours on 23 October 2013, developed a faecal anastomotic leak causing peritonitis and shock, and died following cardiac arrest on 24 October 2013. The substantive concerns were insufficient staffing and failures to recognise deterioration, escalate care, and call the Hospital Crash Team when her blood pressure became unrecordable.

    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 sufficient staffing for patient caseloads

    Wider context from the report

    “(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”

    Source location

    Sari Marlene KEEN · 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 the number of nurses allocated to ward 22 at night following the staffing establishment review.

    Verbatim wording from the response

    “Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

    Source location

    2014-0180-Response-by-Luton-Dunstable-University-Hospital
    Page 1 · response
    Published 16 April 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

    Raise insufficient staffing and early escalation with ward staff through daily safety brief discussions.

    Verbatim wording from the response

    “The following actions have been undertaken to minimise the risk of this happening again:”

    Source location

    2014-0180-Response-by-Luton-Dunstable-University-Hospital
    Page 2 · response
    Published 16 April 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

    Review clinical support available at night across the Trust.

    Verbatim wording from the response

    “• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

    Source location

    2014-0180-Response-by-Luton-Dunstable-University-Hospital
    Page 3 · response
    Published 16 April 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

    Develop a revised hospital-at-night model to provide a robust 24/7 service.

    Verbatim wording from the response

    “• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

    Source location

    2014-0180-Response-by-Luton-Dunstable-University-Hospital
    Page 3 · response
    Published 16 April 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 staffing reviews, risk assessments and on-call arrangements are considered sufficient to ensure adequate medical and nursing staffing.

    Verbatim wording from the response

    “Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

    Source location

    2014-0180-Response-by-Luton-Dunstable-University-Hospital
    Page 1 · response
    Published 16 April 2014

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Pamela Margaret Bailey · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain minimum staffing levels on Hawthorn Ward

    Wider context from the report

    “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place. ”

    Source location

    Pamela Margaret Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 a senior manager solely for management duties

    Wider context from the report

    “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place. ”

    Source location

    Pamela Margaret Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester North

    AI-generated summary

    Barry James LEWIS · 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

    Barry James Lewis suffered an anaphylactic reaction of unknown origin and developed severe airway swelling and difficulty speaking. Despite emergency treatment, attempts to secure his airway were difficult, he suffered respiratory and cardiac arrest, and he died after 50 minutes of resuscitation. The substantive concerns related to the availability and suitability of emergency airway instruments, theatre access, night staffing, and out-of-hours ENT cover across multiple 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

    Inadequate out-of-hours medical cover for ENT service provision

    Wider context from the report

    “6) Staffing levels/adequacy/sufficiency of medical cover, with particular reference to ENT service provision out of hours and geographic/split site commitments. ”

    Source location

    Barry James LEWIS · 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

    Out-of-hours staffing and ENT cover are considered appropriate for the site and trust’s activity.

    Verbatim wording from the response

    “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.”

    Source location

    2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
    Page 2 · response
    Published 22 February 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

    More than one trust-wide middle-grade ENT clinician on call is considered neither clinically nor financially practical.

    Verbatim wording from the response

    “6) Out of hours staffing, like that for ODP’s, is appropriate for the site & the trust. With particular reference to ENT cover it would again neither be clinically or financially practical to have more than one person on call at middle grade level for the trust for the level of activity in that specialty. Where there is a clinical need the consultant would be contacted & asked to come in. As you are aware the trend in medicine is for there to be fewer specialist sites which cover a wider catchment population. Other specialties where this has happened would include cardiothoracic surgery, vascular surgery, ophthalmology, urology & neurosurgery.”

    Source location

    2013-0314-Response-by-The-Pennine-Acute-Hospitals-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    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