Recurring concern

Insufficient medical staffing capacity for timely patient care

First to latest report 7 Jan 2013 — 4 Feb 2026

Reports that mention this concern
57
Times this concern has been raised
61
Stated actions linked to this concern
118

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.

What is 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 and published responses 57 reports

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

  1. 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 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

    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

  2. Leicester City and South Leicestershire

    AI-generated summary

    Dayani Chauhan-Ahmed · 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

    Dayani Chauhan-Ahmed was born in poor condition after a prolonged second stage of labour exceeding 5.5 hours and died after intensive care was withdrawn with parental consent. The substantive concerns included ineffective communication about the length of labour, uncertainty about staff knowledge and adherence to escalation procedures, and insufficient midwifery and medical availability during periods of extreme demand.

    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 midwifery and medical availability during extreme service demand

    Wider context from the report

    “(3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service. The current informal “SOS” system for midwifery attendance, while promising, should be further explored and confirmed in Trust policy if considered to be effective. ”

    Source location

    Dayani Chauhan-Ahmed · 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

    Advertise two additional consultant posts for the maternity service.

    Verbatim wording from the response

    “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.”

    Source location

    Response from University Hospital of Leicester NHS Trust
    Page 3 · response
    Published 30 June 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

    Increase consultant presence through phased extended-hours cover at both delivery suites, including increased Leicester General Hospital and Leicester Royal Infirmary coverage.

    Verbatim wording from the response

    “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.”

    Source location

    Response from University Hospital of Leicester NHS Trust
    Page 3 · response
    Published 30 June 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

    Move to a one-site maternity take in 2019 to improve management of periods of extremely high demand.

    Verbatim wording from the response

    “6. Since this incident occurred the service has advertised two additional consultant posts. It is planned that the maternity service will move toward extended hours of consultant presence on both delivery suites in UHL with a phased increase in consultant numbers. As a first step it is planned that hours of consultant presence at the Leicester General Hospital will increase from its current 60 hours/week to 84 hours/week by the end of September 2014. We also plan to increase hours of cover at the Leicester Royal Infirmary. This will require a reorganisation of consultant job plans and we anticipate that there will be more robust consultant presence with prospective cover at the LRI by end of September 2014. In 2019 it is planned to move to a one-site take and this should better enable the service to manage periods of extremely high demand.”

    Source location

    Response from University Hospital of Leicester NHS Trust
    Page 3 · response
    Published 30 June 2014

    Open published response

  3. Inner West London

    AI-generated summary

    Desiree Harmony Falvo · 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

    Desiree Harmony Falvo developed severe breathing difficulties after a procedure and was transferred to hospital in extremis. Difficulties securing her airway led to cardiac arrest and hypoxic brain injury, and she subsequently died in intensive care. The concerns were insufficient on-site emergency surgical tracheotomy expertise in some A&E departments and the adequacy of training and confidence of clinicians expected to secure airways.

    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 A&E cover by clinicians able to secure airways via emergency surgical tracheotomy

    Wider context from the report

    “(1) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy, ”

    Source location

    Desiree Harmony Falvo · 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

    Review Emergency Departments and senior-staff availability for emergency airway skills across London.

    Verbatim wording from the response

    “Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

    Source location

    2014-0171-Response-by-NHS-England
    Page 1 · response
    Published 15 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

    Implement increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.

    Verbatim wording from the response

    “Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

    Source location

    2014-0171-Response-by-NHS-England
    Page 1 · response
    Published 15 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

    Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.

    Verbatim wording from the response

    “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

    Source location

    2014-0171-Response-by-NHS-England
    Page 1 · response
    Published 15 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

    Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.

    Verbatim wording from the response

    “There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

    Source location

    2014-0171-Response-by-NHS-England
    Page 1 · response
    Published 15 April 2014

    Open published response

  4. Manchester West

    AI-generated summary

    Howard Simon Sankey · 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

    Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff 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

    Insufficient staffing capacity for the large and unpredictable referral volume

    Wider context from the report

    “(1) During the Inquest evidence was heard that :- i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt. ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user. iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team. iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day. Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day. v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013. vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral. 2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to: i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral. iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed. iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners. v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed. vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day. vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period. viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods. ”

    Source location

    Howard Simon Sankey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish full assessment-team staffing, recruit all vacancies and provide rota coverage across the 24-hour period.

    Verbatim wording from the response

    “IV. The work of the assessment team can be unpredictable due to the unplanned nature of referrals. I can confirm that whilst at the time of the incident, the team had gaps in staffing due to sickness and vacancies; the team is now fully established. Sickness continues to be proactively managed at a local level and monitored across the entire business stream in line with Trust policy. Staff work to a rota that ensures maximum coverage across the 24 hour period.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 2 · response
    Published 27 December 2013

    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

    Undertake an Acute Care Pathway review covering staffing, skill mix and pathway effectiveness across teams.

    Verbatim wording from the response

    “VII. The Trust are currently undertaking a review of the entire Acute Care Pathway (ACP) which includes a review of staffing levels and skill mix across all teams and the effectiveness of pathways between services. This is due to be reported at the end of February 2014. The team manager receives regular management supervision where the concerns you have raised have been discussed and action taken.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 3 · response
    Published 27 December 2013

    Open published response

  5. 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 individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate medical cover for geographic or split-site commitments

    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

  6. Manchester South

    AI-generated summary

    Jennifer Elsie RUSHWORTH · 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

    The circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.

    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 surgeon capacity for laparoscopic surgery and urgent patient assessment

    Wider context from the report

    “Thirdly ████████ indicated that there are simply not enough surgeons dealing with this type of laparoscopic surgery and to deal with the number of patient's requiring their care. They are simply unavailable to perform these operations and therefore the operations are later than would often be desirable and this can of course have quite devastating effects. Finally he also indicated that they needed to be seeing this type of patient more urgently and again they cannot do this simply because there are insufficient surgeons available for the number of cases that they are expected to deal with. ”

    Source location

    Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Andrew John Fallon · 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

    Andrew John Fallon was admitted to Stepping Hill Hospital on 9 November 2012 after four days of vomiting and abdominal pain, suffered a cardiac arrest later that day, and died on 15 November after severe neurological damage and withdrawal of ventilator support. Concerns included Emergency Department staffing levels, delays in treatment, and the proposed use of a primary care facility for patients with minor conditions.

    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 Emergency Department staffing to manage patient volume

    Wider context from the report

    “1. I heard evidence from the medical staff and others that the staffing levels within the Emergency Department were such that the doctors simply could not cope with the volume of work, thus leading to inordinate delays in treating the patients. I was specifically informed that there were, as is frequently the case, numerous patients at the Emergency Department with what can only be described as minor or trivial complaints. ”

    Source location

    Andrew John Fallon · Prevention of Future Deaths report
    Page 1 · 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