Recurring concern

Insufficient medical staffing capacity for timely patient care

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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

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

    Peter O’Donnell · Prevention of Future Deaths report

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

    Report summary

    Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.

    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 post-operative medical staffing capacity

    Wider context from the report

    “2. A single Junior Doctor (Resident Medical Officer) was the sole Clinician providing post-operative care for patients. He was on duty 24/7 and asserted that a daily review of each patient would be adequate (although this would be a minimum and would depend on the condition of the individual patient). Both the monitoring and appraisal of each RMO remained with an outside Employment Agency rather than the private hospital in which they were based. Responsibility for training was similarly unclear. ”

    Source location

    Peter O’Donnell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Sussex

    AI-generated summary

    Barbara Joan Howard · 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

    Barbara Joan Howard fell at home on 19 July 2017, experienced delays in ambulance response and backup, and was taken to hospital, where she died from injuries sustained in the fall on 20 July 2017. The concerns included ambulance and clinician staffing shortages, failure to make a priority-assessment call when the response exceeded the target time, and ambulance-call auditing below the stated target.

    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

    Shortage of clinicians in the Emergency Operation Centre

    Wider context from the report

    “(2) In evidence, I heard that when a call is not responded to within the national target time, in this case, 30 minutes, then a Clinician should ring the patient to ascertain the priority of the call within the category. On 19 July 2017 this was not done and they were around 15 clinicians short within the Emergency Operation Centre. I was informed that there are now 9 clinicians in training the Emergency Operation Centre but this still means that there are 6 staff members short. ”

    Source location

    Barbara Joan Howard · 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

    Obtain approval for and implement a project plan introducing recruitment and retention changes for Emergency Operations Centre clinicians.

    Verbatim wording from the response

    “To address this issue, Secamb have created a project plan to address our EOC issues, including the implementation of radical changes to the recruitment and retention of the EOC clinicians. This plan is currently with the Director of Operations for sign-off and will then be presented to the Trust’s Executive for approval, after which it will be implemented. I attach a summary of the plan. Our initiatives also include:”

    Source location

    2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 27 February 2018

    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

    Change call-volume forecasting and review rotas to align clinician capacity with demand.

    Verbatim wording from the response

    “b. A change to the way we forecast volumes of calls, together with a rota review, to try better to align clinician capacity with demand.”

    Source location

    2017-0420-Response-by-South-East-Coast-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 27 February 2018

    Open published response

  3. Southampton and New Forest

    AI-generated summary

    Owen Richard Widlake · 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

    Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide continuous junior doctor or registrar cover for NICU

    Wider context from the report

    “(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff. 2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph. 3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN ii) a lack of empowerment indicating a lack of leadership. 4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves. 5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this. 6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm. 7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover. ”

    Source location

    Owen Richard Widlake · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. South London

    AI-generated summary

    Olaseni 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

    Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.

    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 trained and physically able medical staff

    Wider context from the report

    “(6) The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was not followed and there was a lack of clarity around who was responsible for assessing compliance ”

    Source location

    Olaseni Lewis · 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

    Monitor staff unable to undertake PSTS physical-intervention training and redeploy unable staff to other work areas.

    Verbatim wording from the response

    “Through ward managers, directorate and Clinical Academic Group Leads and the Trust's Education and Training Department, the Trust is closely monitoring whether any of its staff members are unable to take part in any level of PSTS training either temporarily or in the long term. The Trust seeks to ensure that its services always have the minimum number of staff available to provide safe and therapeutic care to its patients which includes the ability of staff members to use PSTS physical interventions in the correct manner. The Trust has redeployed staff to other work areas on the basis that they are unable to perform PSTS physical interventions.”

    Source location

    2017-0205-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 3 · response
    Published 28 July 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 sixth concern is directed to South London and Maudsley NHS Foundation Trust rather than the police service.

    Verbatim wording from the response

    “6. The jury concluded that medical staff requested police assistance due to a lack of trained and physically able medical staff. The Trust had a policy for closing wards or placing them in special measures when training levels fell below a given level, but this was followed and there was a lack of clarity around who was assessing compliance.”

    Source location

    2017-0205-Response-by-Metropolitan-Police
    Page 2 · response
    Published 28 July 2017

    Open published response

  5. Exeter and Greater Devon

    AI-generated summary

    Colin James SLUMAN · 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

    Colin James SLUMAN suffered a burst varicose vein and exsanguinated before emergency services attended. Concerns included that the NHS Pathways protocol did not treat dizziness and being alone as triggers for a rapid response to catastrophic haemorrhage, that call handlers were not clinically trained and relied on the protocol, and that clinical supervision was not continuously available.

    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 availability of Clinical Supervisors to advise call handlers on appropriate responses

    Wider context from the report

    “(3) There are not enough Clinical Supervisors available to call handlers for advice (on appropriate response) at all times, nor do they have constant oversight of all emergency reports. ”

    Source location

    Colin James SLUMAN · 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

    Put funding in place to recruit ten additional clinicians.

    Verbatim wording from the response

    “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 5 · response
    Published 28 July 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

    Review clinicians’ rota arrangements to align availability with demand by time and day.

    Verbatim wording from the response

    “One of the actions recommended following the completion of the Serious Incident report was to increase the clinical support within the clinical hubs to meet the increasing demand. In response, funding was put in place to recruit an additional ten clinicians. A review of the clinicians’ rota has also been undertaken to ensure clinician availability is proportionate to the time of day etc.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 5 · response
    Published 28 July 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

    Introduce a cross-hub hunt group enabling EMAs to obtain support from available clinicians.

    Verbatim wording from the response

    “In response to continual increases in call volume, the Trust has implemented a virtual telephony system to ensure an available call handler, irrespective of location, will take a 999 call on either NHS Pathways or MPDS. To further ensure accessibility of clinical support for EMAs, a ‘hunt group’ was introduced in November 2016 whereby EMAs are able to seek clinical support from available clinicians irrespective of their hub location, thereby maximising the clinical support available to call handling staff.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 6 · response
    Published 28 July 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

    EMAs are not completely reliant on NHS Pathways because clinical escalation, local guidance and supervisory review provide additional safeguards.

    Verbatim wording from the response

    “In terms of whether EMAs are completely reliant on NHS Pathways to reach a disposition, as the Pathways are meticulously devised by a panel of clinical experts, EMAs are for the most part, able to rely on the disposition reached. However, there are occasions where the Trust does not consider a particular disposition (as would be generated by NHS Pathways) for a specific patient presentation to be appropriate despite being clinically safe. On those occasions, the issues are escalated to NHS Pathways for review. Although the Pathways may be revised as a result, if change is not felt to be clinically necessary, it is for the Trust to determine whether local guidance or SOPs should be implemented to govern a particular situation and accordingly any policies would need to be ratified through internal governance procedures.”

    Source location

    2017-0200-Response-by-South-Western-Ambulance-Service
    Page 4 · response
    Published 28 July 2017

    Open published response

  6. Nottinghamshire

    AI-generated summary

    Kate Dolby · 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

    Kate Dolby was found dead at home on 9 October 2016, with the cause of death recorded as Propranolol toxicity; the inquest concluded that her death was suicide. The report identified delays and communication breakdowns in accessing Early Intervention in Psychosis services, with workload, waiting lists and insufficient medical staffing identified as substantive concerns.

    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 medical staffing for EIP patient access

    Wider context from the report

    “At present, it is somewhat reassuring that most patients are being reviewed by care coordinators from an early stage, but it would appear there is an ongoing problem with having enough doctors to see these patients. The system appears to rely currently on care coordinators identifying those in urgent need and trying to arrange appointments for them, sometimes outside of usual clinical hours. This seems a somewhat precarious system, which relies to some extent on the goodwill of the clinicians themselves. The evidence I heard was that an independently commissioned report concluded that the service requires another full-time consultant in the EIP team. I am aware that recruitment in mental health services is often difficult and time-consuming, and therefore consider that the process for this should be considered without delay. I was told that the CCG was to make a decision about a request for further funding shortly after the conclusion of the inquest. The trust requested funding for 6 more nurses and 1 full-time consultant. It is clear that there is an ongoing need for more staff to deal with patients requiring the services of the EIP team. I asked the trust to advise me on the outcome of their funding request, and was subsequently advised ( by email from their legal advisor on 24.4.17) that, at present, funding has been agreed for 3 care-coordinators, an administrator, and 0.4 medic to support EIP access. On the basis of this information, I remain concerned, particularly about funding for further medics, in this team, and have elected to formalise these concerns in a Regulation 28 Report. There were undoubtedly failings and communication breakdowns contributing to the delay in Kate’s case. However I find that the most significant factor in the delay was the workload and waiting list. This was the key cause, certainly from 3 June 2016 onwards, which is very much the bigger part of the delay in this case. The trust has addressed most of these issues and I therefore see no benefit in addressing this report to Nottinghamshire Healthcare NHS Foundation Trust as well. The key area of outstanding concern relates to funding. ”

    Source location

    Kate Dolby · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  7. South Wales Central

    AI-generated summary

    Anton Kusz · 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

    Anton Kusz, an 88-year-old care home resident, fell at breakfast on 5 January, fractured his right hip and was taken to hospital after a delay of over eight hours. He underwent surgery the following day and died on 7 January after a sudden cardiac arrest. The principal concern was the prolonged ambulance delay, including the impact of hospital handover delays and limited ambulance service resources, leaving him on the floor in pain for over eight hours.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient clinician capacity for timely secondary triage of 999 calls

    Wider context from the report

    “(1) There was a delay of over eight hours before an ambulance crew was able to convoy Mr Kusz to the hospital. The initial 999 call was made at 0822 hours and was then chased on at least seven different occasions by the care home and also his General Practitioner who saw him in the position in which he fell 5 hours after the fall. The evidence revealed that the General Practitioner reported an occasional irregular heart beat and asked that an urgent ambulance was sent. It was not until 1447 that a Clinician, employed by the Ambulance Service reviewed and undertook a secondary triage of Mr Kusz’s case which escalated his status to a more urgent case which, if known before may have resulted in an earlier response. The evidence went on to reveal that at that time there were just three Clinicians employed by the Welsh Ambulance Service reviewing all 999 calls for across Wales. One of the main factors accounting for the significant delay was the unavailability of resources/ambulances caused by extensive delays at hospitals across the region handing over patients at Accident and Emergency Departments. Delays of three to four hours were widely reported when the optimum period of time is fifteen minutes. This was so even though the escalation policy to “level three” (indicating severe pressure on the system) was in operation. Whilst the evidence was equivocal as to whether the delay had directly led to Mr Kusz’s death the fact that an 88 year old gentleman with a serious injury such as a fractured hip had to remain on the floor in the same position in pain for over eight hours raises a real concern for the safety of others. ”

    Source location

    Anton Kusz · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. East London

    AI-generated summary

    Peter Daniel Usher · Prevention of Future Deaths report

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

    Report summary

    Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

    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 medical staffing for Section 136 assessments

    Wider context from the report

    “5. The junior doctor gave evidence to confirm that he was the only doctor available for 11 wards and 200 patients. It would appear from information provided by the Trust, that the number of Section 136 assessments is increasing substantially and therefore there is a concern in relation to adequate medical staffing. ”

    Source location

    Peter Daniel Usher · 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 the Goodmayes on-call doctors’ workload and undertake a follow-up audit of junior doctors’ workload and the impact of changes.

    Verbatim wording from the response

    “5 | NELFT is currently in the process of reviewing the workload of the Goodmayes on call doctors. We aim to implement changes by beginning of February. An audit on junior doctor on call workload will be undertaken at the beginning of March 2017 to see if the changes have had an impact on their workload, and what other measures can be put in place to reduce the pressure associated with the workload, when completing s136 assessments.”

    Source location

    2016-0428-Response-by-NELFT-NHS-Trust
    Page 3 · response
    Published 19 February 2017

    Open published response

  9. Manchester West

    AI-generated summary

    Karen Ann Thorne · 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

    Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.

    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 radiologist training capacity

    Wider context from the report

    “1. During the Inquest evidence was heard that:- i. There are delays in reporting neuroradiology within the Salford Royal NHS Foundation Trust and at the present time the longest wait is 60 days, which is a slight improvement from the end of 2015 when the Scan conducted on the Deceased was not reported for 65 days but a delay of 60 days is still unacceptable. ii. There is an increasing demand for neuroradiology, and radiology in general, and there is a national shortage of Radiologists. iii. The delay in reporting radiology is of greater concern in cases where a patient is receiving treatment on a regular basis, namely every 28 days in the case of the Deceased, and the Scans are not reported for a period in excess of 60 working days, during which time the Deceased received 2 or 3 additional Natalizumab infusions, which would have been stopped had the Scan been reported and identified PML before the next infusion. iv. Evidence was given at the Inquest, on the basis of information received from the Royal College of Radiologists, that the national shortage of Radiologists was due to the fact that there are a fixed number of training positions for Radiologists each year and the number is insufficient to produce the number of Radiologists required to give an appropriate service and to report radiology within a reasonable, necessary and expected time period. The information referred to the fact that there was no shortage of clinicians prepared to train as Radiologists and that there were more applicants than training positions. The evidence given to the Inquest was that an increase in the number of training positions would increase the number of Radiologists to address the national shortage of Radiologists, which is creating the delays in reporting radiology and delays in the diagnosis of conditions requiring either immediate treatment or the cessation of treatment with recognised complications. 2. I request you to consider the above concerns in relation to a national shortage of Radiologists and to review the number of training positions to address the national shortage of Radiologists and to address delays in the reporting of radiology and the diagnosis of disease, either requiring treatment or the cessation of treatment. ”

    Source location

    Karen Ann Thorne · Prevention of Future Deaths report
    Page 3 · 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

    Responsibility for addressing radiologist shortages and developing diagnostic workforce plans lies with Health Education England and its partners.

    Verbatim wording from the response

    “Some of the matters you raise are for the Trust. For the concerns you raise about the shortage of radiologists, Department of Health officials have contacted Health Education England about its plans to recruit more trainees into radiology. I understand Health Education England is working in partnership with NHS England and a range of professional bodies to develop a shared vision and strategy for the diagnostics workforce. Clinical Radiology is a priority area.”

    Source location

    2016-0408-Response-by-Department-of-Health
    Page 1 · response
    Published 11 November 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Some matters raised in the concerns are the responsibility of the relevant NHS Trust rather than the Department of Health.

    Verbatim wording from the response

    “Some of the matters you raise are for the Trust. For the concerns you raise about the shortage of radiologists, Department of Health officials have contacted Health Education England about its plans to recruit more trainees into radiology. I understand Health Education England is working in partnership with NHS England and a range of professional bodies to develop a shared vision and strategy for the diagnostics workforce. Clinical Radiology is a priority area.”

    Source location

    2016-0408-Response-by-Department-of-Health
    Page 1 · response
    Published 11 November 2016

    Open published response

  10. East London

    AI-generated summary

    Mrs Catherine Dinnen · Prevention of Future Deaths report

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

    Report summary

    Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate out-of-hours medical staffing

    Wider context from the report

    “2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”

    Source location

    Mrs Catherine Dinnen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026