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. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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

    Excessive patient caseloads and unclear experience among senior resident medical staff

    Wider context from the report

    “1. The admission of an acutely unwell patient with pneumonia to a private hospital dealing primarily with elective surgical procedures with no HDU/ITU facilities in case of deterioration. The most senior doctor in the hospital, other than visiting clinicians was an RMO of unclear experience who usually has the care of more than 50 patients at any one time but can be as many as 72. This is alongside nursing staff who have no significant grounding in resuscitation and an unclear understanding of chest drain insertion for pneumonic pleural effusions, usually having to deal with malignant pleural effusions. ”

    Source location

    Mr Critall · 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

    Require RMOs to meet hospital-specific experience and competency criteria, selecting familiar RMOs to improve continuity and consultant communication.

    Verbatim wording from the response

    “1. Any RMO’s offered to the hospital are required to meet specific criteria regarding previous experience and competency and a number of RMOs have been specifically selected who are familiar with the hospital, the consultants and nursing staff with the aim of improving continuity of care and communication with consultants.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 2 · response
    Published 16 May 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

    The RMO met hospital-specific requirements, including GMC registration, life-support certification and relevant clinical experience.

    Verbatim wording from the response

    “Resident Medical Officer (RMO) - The role of the RMO is to respond to requests from consultants and nursing staff in matters which require medical input and involves the assessment of surgical and medical patients who deviate from the treatment pathway, and deteriorating patients. RMO’s are provided to the hospital by an agency and are provided on the basis that they are able to work within the clinical requirements specific to the hospital, including GMC registration, a current Advanced Life Support certificate and European Paediatric Life Support certificate and experience in cancer care. This was the case for the RMO on duty that day. At the time of Mr Critall’s admission, the hospital was registered for 72 beds.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 2 · response
    Published 16 May 2016

    Open published response
  2. Inner North London

    AI-generated summary

    Marina Fagan · 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

    Marina Fagan was admitted to hospital with headaches, later developed confusion, visual loss and eye movement palsy, and was diagnosed with PRES before dying on 6 October 2015. The report raised concerns about the availability of specialist neurological care, including delays in neurology input and limited out-of-hours neurologist provision, and noted that future deaths could occur in similar circumstances.

    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 specialist neurological care

    Wider context from the report

    “This witness set out his concern that, nationwide, there are insufficient neurologists to provide necessary specialist care. He noted that in the out of hours setting, although there were neurologists available the nearby tertiary care hospital, none were on-call in the hospital to which Ms Fagan was initially admitted. Ms Fagan's general practitioner set out that the current waiting time to see a neurologist in the outpatient setting, is 72 days. Given the issues regarding availability of specialist neurological care, I am concerned that future deaths will occur in similar circumstances. ”

    Source location

    Marina Fagan · 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

    Barts Health NHS Trust is responsible for addressing local neurologist availability and staffing levels.

    Verbatim wording from the response

    “It is the responsibility of providers to ensure that they have appropriate staffing levels to meet the needs of their patients. The availability of neurologists locally is therefore for Barts Health NHS Trust to address.”

    Source location

    2016-0162-Response-by-Department-of-Health
    Page 1 · response
    Published 22 April 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

    Health Education England is responsible for planning the national neurology workforce and commissioning training places.

    Verbatim wording from the response

    “On a national basis, Health Education England (HEE) plans the future workforce. HEE has consistently invested in the commissioning of training places in neurology and intends to commission 219 training places in 2016/17, a small rise from 217 in both 2014/15 and 2015/16.”

    Source location

    2016-0162-Response-by-Department-of-Health
    Page 1 · response
    Published 22 April 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

    National neurology waiting times meet the operational NHS waiting-time standard, so existing arrangements address the national concern.

    Verbatim wording from the response

    “Where this is not possible, the NHS should take all reasonable steps to offer a range of suitable alternative providers able to see or treat the patient more quickly than the original provider, if this is what the patient wants and it is clinically appropriate. Commissioners are not obliged to take all reasonable steps to find an alternative provider if the patient does not ask for this. Some patients will wait longer than 18 weeks by choice, for personal or social reasons, or because this is clinically appropriate.”

    Source location

    2016-0162-Response-by-Department-of-Health
    Page 2 · response
    Published 22 April 2016

    Open published response
  3. Manchester South

    AI-generated summary

    Freda Weston · 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

    Freda Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.

    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 capacity for patient review

    Wider context from the report

    “4. The junior doctor gave evidence that s/he was unable to “get round to seeing” this patient as there was insufficient doctor-time to do so on that shift. The doctor went on to say “this is not an uncommon situation”. The hospital as a whole was being covered by one FY1 doctor and two SHO’s, one of whom was “clerking in” the new patients. This meant that the FY1 was covering 13 wards of the hospital. Clearly an impossible task. ”

    Source location

    Freda Weston · Prevention of Future Deaths report
    Page 1 · 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 arrangements, including prioritisation and access to senior clinicians, were considered adequate for urgent reviews and emergencies.

    Verbatim wording from the response

    “There is no on-call national guidance with regards to staffing numbers and broadly the total number of on-call doctors in Stepping Hill Hospital is the same for most district general hospitals of a similar size. Out of hours on-call work is primarily for urgent reviews and emergencies.”

    Source location

    Weston-Response
    Page 2 · response
    Published 23 February 2016

    Open published response
  4. Surrey

    AI-generated summary

    Clifford Irwin Crofts · 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

    Clifford Irwin Crofts, who had Parkinson’s disease and aspiration difficulties, was admitted to hospital and underwent insertion of a radiologically inserted gastrostomy tube on 19 September 2014. He experienced acute pain after feeding began, but there were delays in escalating his care, obtaining a CT scan and carrying out surgery; he subsequently developed respiratory difficulties and died on 10 October 2014. The substantive concerns included failure to follow the RIG care plan, difficulties escalating care, delays in obtaining urgent CT imaging, and weekend 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

    Insufficient numbers of doctors at all levels of seniority available at weekends

    Wider context from the report

    “(4)During the course of evidence it became clear that the delay in attempts to escalate Mr Crofts’ care over the weekend was due in large part to staffing levels. Whilst I heard that staffing levels at weekends have increased since 2014, it was not clear that the number of doctors at all levels of seniority available at weekends is sufficient to provide safe care to in patients at the hospital particularly at times when emergencies arise in A and E. ”

    Source location

    Clifford Irwin Crofts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide an additional doctor on the emergency medical take from 16:00 to 23:00 every day through adjusted junior-doctor rotas.

    Verbatim wording from the response

    “• We have recently adjusted the medical junior doctor rotas such that there is an extra doctor on the emergency medical take from 16:00 to 23:00 every day.”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 2016

    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

    Define minimum safe medical staffing levels for each clinical area and doctor grade through a Medical Director-led workstream.

    Verbatim wording from the response

    “• In contrast to nursing practice, there is no guidance as to what constitutes ‘safe staffing’ for doctors. This is an issue we are trying to address at Ashford and St Peter’s and the Medical Director is leading a work-stream which is attempting to define, for each clinical area and each grade of doctor, the safe minimal level of medical staffing.”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 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

    Current contractual restrictions limit the ability to roster doctors for elective work during premium time, constraining implementation of identified safe staffing levels.

    Verbatim wording from the response

    “It is likely the implementation of identified safe staffing levels for doctors will require the introduction of the new contracts for both junior doctors and consultants as at present there are significant restrictions on our ability to roster doctors to perform elective work within ‘premium time’ (19:00 to 07:00 weekdays and any time at weekends).”

    Source location

    Clifford-CROFTS-Response
    Page 3 · response
    Published 22 February 2016

    Open published response
  5. Birmingham and Solihull

    AI-generated summary

    Doreen England · 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

    Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

    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 on-site medical cover

    Wider context from the report

    “(3) Rosemary suite had no leadership at the time. Staff were completing paperwork but not then actioning risks that were identified. The consultant and ward doctor were on leave at the same time and medical cover was only available from doctors off site who had to be requested to attend. The ward and trust need to ensure there is clear leadership on the ward with adequate medical cover. ”

    Source location

    Doreen England · 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

    Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.

    Verbatim wording from the response

    “It is also a significant concern that at the time of the inquest the organisation involved does not appear to have responded in correcting these issues. We are in communication with Birmingham Cross City CCG which has undertaken a significant amount of work in relation to this case already and who commission the service and will also ensure CQC are aware of the case.”

    Source location

    2015-0291-Responses
    Page 7 · response
    Published 23 July 2015

    Open published response
  6. Inner North London

    AI-generated summary

    Sabrina Stevenson · 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

    Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

    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 trained paramedics due to vacant positions

    Wider context from the report

    “(2) I am concerned by evidence provided from LAS that there are 400 vacant positions within the Trust. This connotes a significant recruitment issue for the profession, which could risk future deaths occurring simply through a lack of available trained paramedics; ”

    Source location

    Sabrina Stevenson · 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

    Assure delivery of the LAS Improvement Programme through the NHS England LAS Oversight Group and regular assurance of the lead commissioner.

    Verbatim wording from the response

    “NHS England and the CCGs undertook a systematic review of the staffing and operational delivery of the London Ambulance Service from January to March 2015. Through the annual contract, CCGs have now invested an additional £19m in an LAS Improvement Programme for 2015/16. This programme will ensure appropriate staffing numbers to enable the delivery of national targets and the timely arrival of ambulances or other LAS resources to patients in need. Implementation of the programme will be governed by an LAS Contracts and Performance Group. The Group will review achievement of a number of metrics including ambulance response times. NHS England will assure delivery through the NHS England LAS Oversight group during 2015/16 and regular assurance of the lead commissioner - Brent CCG.”

    Source location

    2015-0126-Response-by-NHS-England1
    Page 3 · response
    Published 30 March 2015

    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

    Recruit 850 staff, including approximately 150 new posts, to increase staffing and capacity.

    Verbatim wording from the response

    “The additional money will be spent increasing staffing and capacity to help us better manage peaks in demand from our patients and to improve our ability to give staff re-breaks during their shifts. A total of 850 staff will be recruited this financial year, which includes around 150 new posts. We are also investing in new ambulance vehicles, and specialist clinical teams in the clinical hub to support GP and primary care referrals.”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 2 · response
    Published 30 March 2015

    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 promoting paramedic careers through the College website.

    Verbatim wording from the response

    “1. Through our website, we will continue to promote the paramedic profession as an attractive and rewarding career;”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 4 · response
    Published 30 March 2015

    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

    Write to ambulance services and higher education institutions offering assistance with paramedic recruitment activities.

    Verbatim wording from the response

    “2. We will write to all NHS ambulance services as employers of paramedics and to HEIs to offer our assistance in their activities which aim to recruit student paramedics and paramedics. We will do this by 5 June 2015”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 4 · response
    Published 30 March 2015

    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

    Apply for student paramedics to be included in the NHS Bursary Scheme.

    Verbatim wording from the response

    “2. The College made application to the Department of Health on 16 August 2012 for student paramedics to be included in the NHS Bursary Scheme and the final decision is due to be recommended to the Department of Health by HEE in June 2015”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 4 · response
    Published 30 March 2015

    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 College does not commission paramedic education, limiting its role in addressing paramedic recruitment and training capacity.

    Verbatim wording from the response

    “The College of Paramedics does not commission education for paramedics. However, the College has previously responded to consultations by the Centre for Workforce Intelligence (CfWI) and has noted that in early 2015 the Migration Advisory Committee has recommended that paramedics qualified to NQF 6+ should be included in the shortage occupation list.”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 4 · response
    Published 30 March 2015

    Open published response
  7. Nottinghamshire

    AI-generated summary

    Philip Robinson · 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

    Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.

    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

    Unavailability of senior medical review when a registrar is absent

    Wider context from the report

    “The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ ”

    Source location

    Philip Robinson · 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

    Continue recruiting senior medical staff to reduce out-of-hours registrar-cover gaps.

    Verbatim wording from the response

    “• The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours. In 2015 to date there has been three occasions where no cover could be obtained. On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust. We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of hours. Similar hospital sites have implemented this system with good outcomes with regards patient safety.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 2015

    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

    Consider alternative ways to deploy senior Trust staff to provide out-of-hours support.

    Verbatim wording from the response

    “• The risk of there being no one available to provide senior medical review when a registrar is absent remains an ‘extreme risk’ This is now no longer seen as an acceptable option to leave a SHO without registrar cover out of hours. In 2015 to date there has been three occasions where no cover could be obtained. On these occasions the consultant on-call was informed and provided extra support to the SHO. The issue around senior medical staffing remains a concern within the Trust. We currently have an ongoing recruitment programme and are considering alternative ways to utilise senior staff within the trust to support this. The hospital 24/7 program is aimed at providing senior nurse practitioner cover to support the hospital out of hours. Similar hospital sites have implemented this system with good outcomes with regards patient safety.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 2015

    Open published response
  8. Manchester South

    AI-generated summary

    Neil Thomas Westerman · 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

    Neil Thomas Westerman attended Stepping Hill Hospital for an elective cholecystectomy on 2 July 2014, after which a bile leak caused septicaemia. Concerns included the pre-operative assessment being conducted by a junior doctor, incomplete operation notes about equipment and materials, and insufficient junior doctors available in practice, particularly at night.

    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 junior doctor staffing to cover patient needs

    Wider context from the report

    “3. I heard evidence, as I have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night. It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available. ”

    Source location

    Neil Thomas Westerman · 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 general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    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 junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    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

    Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.

    Verbatim wording from the response

    “Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

    Source location

    2015-0091-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 11 March 2015

    Open published response
  9. Staffordshire South

    AI-generated summary

    Peter Jonathan Wright · 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 Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

    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 out-of-hours doctor cover at the hospital

    Wider context from the report

    “(2) At the time of this incident there was still a 24 hour Emergency Department at the nearby Stafford Hospital and at St George’s Hospital there was no doctor on site. Now the Emergency Department at County (formerly Stafford) Hospital is not open during the night and the nearest ED is at Stoke. I was told that the situation can be managed by calling paramedics. While I appreciate that nearly all the doctors at St George’s are psychiatrists not medics I wonder if any consideration has been given to out of hours cover by a doctor? ”

    Source location

    Peter Jonathan Wright · Prevention of Future Deaths report
    Page 1 · 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

    Non-resident medical cover, trained staff, emergency equipment, basic life support and 999 access are considered sufficient for out-of-hours medical emergencies.

    Verbatim wording from the response

    “The Trust does not have resident doctors on call but operates a non-resident out of hour’s rota to comply with European Working Time Directive.”

    Source location

    2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
    Page 2 · response
    Published 2 March 2015

    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

    Paramedics are considered best placed to provide advanced emergency support and stabilisation before transfer to hospital.

    Verbatim wording from the response

    “Every clinical and non-clinical area has first aid in place and wards are stocked with equipment for managing common emergencies. We do however recognise that more sophisticated medical equipment and support may be required at times, and in the case of a medical emergency we expect staff to call 999 without delay, as this is what people in the community would do in similar circumstances.”

    Source location

    2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
    Page 2 · response
    Published 2 March 2015

    Open published response
  10. London (East)

    AI-generated summary

    Iana-Liza Chervonenko · 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

    Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became 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 medical cover on the labour ward

    Wider context from the report

    “1. The Labour Ward was very busy on the night of 7/8th March 2014. The levels of activity on the ward resulted in the following: • A delay in obtaining a medical review to the concerning CTG trace. • A period of 40 minutes before a medical review, following the consultant noting a pathological CTG trace. • Incorrect documentation in relation to the grading of the caesarean section. • Due to the activity on the Labour Ward the obstetric registrar was not able to fully record his assessments of the patient. • The obstetric registrar confirmed that he did not speak to the anaesthetist about the type of anaesthesia to be used due to him being busy with other patients. 2. ████████ had concerning risk factors of reduced foetal movements and a pathological CTG trace. There were no reassuring reasons for the changes in fetal heart rate. A pathological CTG in an antenatal patient with a history of reduced foetal movements should result in a Grade 1 caesarean section. She should have been delivered by 00.40. The theatre is likely to have been free by 00.22. There was however no communication with the treating team of the availability of theatre and this was only noted by the labour ward coordinator whilst conducting her general rounds at around 00.40. Had ████████ been taken to theatre at 00.22, the consultant has confirmed that Iana-Liza would have been delivered by 00.40. I am concerned about the level of medical cover on the labour ward. The consultant has confirmed that Queens Hospital Maternity Unit is a very busy unit. The level of activity on the 7/8th March 2014 did result in care being provided which contributed to the death of Iana-Liza. The doctors were under severe pressure due to the amount of work and all of the doctors who gave evidence confirmed that further medical support on the maternity unit would improve the care provided to patients. A safe system of care would include the clear and accurate documentation of clinical reviews and clinical decisions; fully informed and thorough discussions with colleagues about prioritisation; fully informed discussions with anaesthetists in relation to the type of anaesthesia required and clear communication between the medical team and midwifery team. The limited number of doctors available on the ward at the time resulted in deficient communication and documentation. I also heard that there is currently no system in place for theatre staff to proactively notify the treating team when the theatre becomes available. I did hear that it would be possible for the Standard Operating Protocol for theatre to be amended to require the Maternity Care Assistant to notify the treating team as soon as theatre becomes free (where a patient is awaiting theatre). No steps had however been taken to address this at the time of the Inquest. ”

    Source location

    Iana-Liza Chervonenko · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026