First reported 7 Jan 2013•Latest report 4 Feb 2026
Definition
What this concern includes
Includes failures of doctor or medical staffing capacity, coverage, availability or resilience that delay or prevent timely patient review, assessment, emergency response, clinical queries, home visits or other required patient care.
Not included
Excludes delays or failures caused by non-staffing factors such as escalation, appointment management, documentation, information access or clinical decision-making when adequate staffing is available.
Excludes poor-quality assessment or review where the evidence does not identify insufficient medical staffing capacity as the unsafe condition.
Excludes staffing deficiencies unrelated to timely patient care, such as excessive working hours without a supported patient-care impact.
Reports
57
Distinct published reports
Individual concerns
61
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
118
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care14
NHS England11
Stockport NHS Foundation Trust3
Barts Health NHS Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
Royal College of Emergency Medicine2
Royal College of Paediatrics and Child Health2
Royal College of Radiologists2
South Western Ambulance Service NHS Foundation Trust2
University Hospitals Birmingham NHS Foundation Trust2
University Hospitals of Leicester NHS Trust2
Aneurin Bevan University LHB1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Betsi Cadwaladr University LHB1
NHS trust34
Ministerial department14
Executive non-departmental public body11
Healthcare site6
Health professional body6
Local health board4
Private limited company4
Integrated care board3
Type not available3
Multi-service care provider2
Professional body2
Company limited by guarantee1
Coronial office1
Devolved government1
Health and care professional regulator1
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.
South Wales Central
Concerns raised2
Lack of cross-cover for geriatric perioperative care during consultant absence
Failure to establish year-round cross-cover within a doctor’s job plan
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Use interim escalation, specialty review and structured documentation arrangements to provide POPS result cross-cover.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 4 February 2026.
Action
Develop a POPS cross-cover rota.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2026.
Action
Prioritise consultant workforce expansion to support 52-week POPS service continuity.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2026.
Action
Embed senior decision-making resilience within emergency and surgical pathways.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2026.
Action
Implement a strengthened SOP requiring telephone communication, escalation and documentation for critically low Vitamin B12 results.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 4 February 2026.
Action
Reinforce senior-clinician WCP result review and conduct twice-weekly POPS checks for abnormalities.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 4 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Organisational financial constraints prevent immediate completion of POPS service expansion and additional consultant workforce, although expansion remains an ongoing strategic objective.
Stated by Cardiff & Vale University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cumbria
Concerns raised1
Insufficient overnight capacity to triage waiting calls
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 15 July 2025.
Action
Implement the clinical review findings by expanding overnight support for 999 call handlers and clinicians and providing urgent in-home care with next-day follow-up.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 15 July 2025.
West Yorkshire Eastern
Concerns raised1
Limited nursing and medical support available to the SJUH site
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Rewrite training rotas and enhance pay and banding support for Advanced Nurse Practitioners.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.
Action
Implement clinical protocols, including intensive and high-dependency care centralisation, daily safety huddles, consultant-led cover and transfer of sick neonates to LGI.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Action
Recruit additional consultants and advanced clinical practitioners to strengthen neonatal staffing.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.
Action
Submit a business case to increase the consultant workforce to 18 whole-time equivalents.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Action
Establish an Executive-led group to review the neonatal care model and safe staffing across both sites.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Action
Complete a full review of neonatal service risks, controls, gaps and mitigation strategies with commissioners and the ODN.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual NHS trusts and employers are responsible for ensuring sufficient staffing for safe care and should review staffing levels.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Insufficient haematology department staffing and capacity for comprehensive reviews
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Increase transplant capacity by reallocating an existing consultant’s job plan to provide more transplant-dedicated time.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Extend the senior specialist registrar’s training for six months, focusing on myeloid disease and allogeneic transplantation while supporting transplant clinics under supervision.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Create and recruit an additional myeloid transplant consultant post.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Action
Create a joint UHB–NHSBT consultant post covering transplant medicine, cellular therapies, laboratory oversight and cross-organisation communication.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Monitor recruitment to the new consultant posts and report progress through the Hospital Board.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual NHS trusts and other employers are responsible for ensuring sufficient staffing for safe care.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Regulation 18 already requires trusts to review staffing numbers and skills needed to provide safe care.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Somerset
Concerns raised1
Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Work with regions and Integrated Care Boards to improve nationwide access to good menopause care.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 25 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England and the Royal Colleges are better placed to address the lack of NHS menopause specialists and services.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England and the Royal Colleges are better placed to address the lack of specialist menopausal care and GP upskilling.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Understaffing of the emergency department, including insufficient staff to take basic observations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Maintain augmented paediatric consultant cover from 09:00 to 23:00 on weekdays.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Provide augmented medical and nursing staffing, including a 24/7 Emergency Department Assistant, using bank and agency cover pending establishment approval.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Review the business case for a Clinical Practice Educator, Emergency Department Assistant and additional paediatric emergency-department nursing establishment.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Review day and night emergency-department staffing skill mix.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Action
Conducted work to identify where paediatric rota gaps most significantly affect services.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Continue advocating locally and nationally for active reduction of paediatric rota gaps.
Stated by Royal College of Paediatrics and Child HealthStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Nursing staffing was in line with safe establishment levels, apart from one registered-nurse rota gap before Billie’s attendance.
Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The response cannot comment on the hospital emergency department’s staffing model, staffing numbers or skill mix.
Stated by Royal College of Emergency MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Delays in medical review due to doctor staffing levels
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement changes and processes to ensure patients are properly informed of their imaging results.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Insufficient doctor staffing capacity in the department
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Complete demand-and-capacity modelling to define the substantive workforce needed for additional resilience.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current emergency department staffing, rota review and escalation processes are considered sufficiently resilient and meet RCEM minimum criteria.
Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Senior doctors consider staffing levels appropriate, disputing that junior orthopaedic staffing levels were dangerous.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Wales (East and Central)
Concerns raised1
Insufficient doctors and nurses for Emergency Department patient demand
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Continue expanding consultant staffing in the Emergency Department, now providing 8.6 whole-time-equivalent consultants plus one locum.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Action
Map the Emergency Department resource required to meet demand and national recommendations.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
Action
Review and increase the Emergency Department nurse staffing roster template through the annual staffing review.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 28 December 2023.
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Includes failures of doctor or medical staffing capacity, coverage, availability or resilience that delay or prevent timely patient review, assessment, emergency response, clinical queries, home visits or other required patient care.
