Recurring concern

Failure to provide adequate and accessible staff induction

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First reported 30 Jan 2014•Latest report 19 Oct 2025

Definition

What this concern includes

Includes failures of the general staff-induction process, including absent or inadequate induction content and failure to provide an accessible alternative induction route for new joiners unable to attend in person.

Not included

  • Excludes ongoing, refresher or specialist training after induction unless the report explicitly identifies the general induction process as deficient.
  • Excludes role-specific competence, qualification or supervision failures where staff induction is not the shared unsafe condition.
  • Excludes generic training, documentation or staffing deficiencies that do not directly concern provision or adequacy of staff induction.
  • Excludes induction for patients, service users or non-staff participants.
Reports
16

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
19

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Ashford and St Peter'S Hospitals NHS Foundation Trust1
Bamford Grange Care Home1
Birmingham Community Healthcare NHS Foundation Trust1
Cygnet Behavioural Health Limited1
Department of Health and Social Care1
Greater Manchester Police1
Guest Medical Limited1
Hc-One Limited1
Hill Care Group1
HM Prison and Probation Service1
Lancashire Constabulary1
Leeds Teaching Hospitals NHS Trust1
Leicestershire Partnership NHS Trust1
Medicines and Healthcare products Regulatory Agency1
Mid and South Essex NHS Foundation Trust1

Concerns and responses across reports

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

  1. Manchester West

    AI-generated summary

    Robert Charles Rostron · 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

    Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.

    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 formal induction and orientation for agency nurses

    Wider context from the report

    “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time. ”

    Source location

    Robert Charles Rostron · 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

    Complete and distribute a strengthened agency-staff orientation booklet across the company.

    Verbatim wording from the response

    “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.”

    Source location

    2019-0237-Response-by-The-Kind-Care-Company
    Page 1 · response
    Published 13 September 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

    Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.

    Verbatim wording from the response

    “As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home.”

    Source location

    2019-0237-Response-by-The-Kind-Care-Company
    Page 3 · response
    Published 13 September 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

    Store agency profiles with completed orientation booklets in Cornerstone and allow agency workers to retain booklet copies.

    Verbatim wording from the response

    “The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.”

    Source location

    2019-0237-Response-by-The-Kind-Care-Company
    Page 3 · response
    Published 13 September 2019

    Open published response
  2. Leicester City and South Leicestershire

    AI-generated summary

    John Charles Hazlewood · 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

    John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to monitor the outcomes of amended induction processes

    Wider context from the report

    “3. The court was assured that the induction process had been changed to improve knowledge regarding on call procedures and availability of medical record access. No information was available, via audit, of whether this amended process is successful. LPT should ensure that the outcomes of their welcome changes are being effectively monitored to ensure clinicians have appropriate training and understanding given the frequent rotations of staff and the importance of the on call system being robust and reliable. ”

    Source location

    John Charles Hazlewood · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Inner South London

    AI-generated summary

    James O’Brien · 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

    James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

    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 ensure agency nurses are familiar with the ward before starting duties

    Wider context from the report

    “(9) The agency nurse in charge of the ward was called shortly before the shift started, was not familiar with the ward, and did not have time to read the care plans of the patients before starting his duties. ”

    Source location

    James O’Brien · 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

    Failure to provide adequate staff induction

    Wider context from the report

    “(8) There was a failure to provide adequate induction to staff. ”

    Source location

    James O’Brien · 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 induction processes to cover record keeping, observation and emergency response, including orientation tours for unfamiliar staff.

    Verbatim wording from the response

    “5. Induction – the hospital had already reviewed its induction processes. This specifically includes the topics of record keeping, observation and responding to emergencies. Staff that are not familiar with the hospital are provided with a “tour” by more experienced staff when they first start work at the hospital. The hospital is committed to using its own staff and their pool of bank staff wherever possible rather than agency staff. To ensure appropriate staffing levels on any particular shift, managers are required to plan bank staff cover in advance to address planned staff absences. Since August 2016, no agency staff have been used at the hospital.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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 an agency-nurse induction protocol requiring short-notice staff to attend early and receive policy and environmental orientation.

    Verbatim wording from the response

    “However, notwithstanding the commitment to no longer employing agency staff on an ad hoc basis, it is impossible to say that this could “never” occur because of the obvious need to ensure appropriate staffing levels and the fact that emergencies might arise where additional staff cover is required. Accordingly, our client has developed and implemented an “agency nurse induction protocol” aimed specifically at any staff who may be booked at short notice to cover a shift. They are required to attend work one hour before the shift commences to go through an induction, and receive orientation to key policies and the environment.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 3 · response
    Published 24 March 2017

    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 former operator no longer controls future hospital safety steps, which fall to the successor operator.

    Verbatim wording from the response

    “The Churchill Hospital was at the date of Mr O’Brien’s death operated by Cambian Healthcare Limited which was then part of our Group. However, in December 2016 we sold our adult services division, including Cambian Healthcare Limited. The Group, therefore, no longer has any executive responsibility in relation to the hospital. Cambian Healthcare Limited is now a subsidiary of Cygnet Healthcare Limited and its Chief Executive Officer is Dr Tony Romero.”

    Source location

    2017-0082-Response-by-Cambian-Group-PLC
    Page 1 · response
    Published 24 March 2017

    Open published response
  4. Manchester South

    AI-generated summary

    George Hulme · 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

    On 25 June 2014, George Hulme was assaulted by another resident at Bamford Grange Nursing Home, collapsed and required CPR. The wrong resident file, which recorded a DNR, was retrieved after he was incorrectly identified, and CPR ceased; concerns included inadequate resident identification systems, induction and room labelling for agency staff and emergency responders.

    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 adequately induct and familiarise agency staff with residents and identification methods

    Wider context from the report

    “2) Agency members of staff are supposed to have an induction and tour of the home upon their first visit. This did not take place adequately to sufficiently familiarise the staff with the residents or any method of correctly identifying residents. ”

    Source location

    George Hulme · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Surrey

    AI-generated summary

    William George KENT · 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

    William George KENT was admitted to hospital after a fall and later developed acute respiratory distress after Haz-Tab granules were used on urine near his bed. He was transferred for further treatment but died after chlorine inhalation was identified as a significant contributing trigger. Concerns included insufficient awareness and training about the hazards and appropriate use of Haz-Tab granules, including the release of noxious gases when they contact urine.

    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

    Limited teaching of cleaning products’ side-effects during staff induction and mandatory infection control updates

    Wider context from the report

    “2. Limited time given over to the teaching of the side-effects of cleaning products such as Haz-Tab granules at the induction of new staff and at yearly mandatory infection control updates ”

    Source location

    William George KENT · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Tallulah Mary Scarlett WILSON · 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

    Tallulah Wilson, a fifteen-year-old schoolgirl, died after jumping in front of a train and taking her own life. The report highlighted concerns about healthcare professionals’ limited understanding of young people’s online lives and the need for research, improved clinical practice, risk-assessment refinement and relevant training.

    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 include digital lives basic training and audit in standard induction training

    Wider context from the report

    “Digital lives basic training and audit is already available, but is not part of standard induction training to raise awareness for all in psychiatric and psychological fields, let alone for all doctors. ”

    Source location

    Tallulah Mary Scarlett WILSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026