Recurring concern

Unsafe assignment of staff without the required qualifications or competence to care work

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First reported 3 Dec 2013•Latest report 2 Feb 2026

Definition

What this concern includes

Includes failures to ensure that staff assigned care work are appropriately qualified for the required duties, including inadequate qualification assurance and assignment of unqualified staff where qualified staff are required.

Not included

  • Excludes staffing shortages or numerical under-resourcing where inadequate qualifications are not material.
  • Excludes training, supervision, documentation or allocation failures unless they directly concern whether staff are suitably qualified for the care work assigned.
  • Excludes failures involving non-care roles or hazards unrelated to staff qualification for assigned care duties.
Reports
17

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
21

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.

NHS England3
Department of Health and Social Care2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Circle Health Group Limited1
Croydon Health Services NHS Trust1
General Medical Council1
Greater Manchester1
Greater Manchester Mental Health NHS Foundation Trust1
Hc-One Limited1
HCRG Care Ltd1
Kent and Medway Mental Health NHS Trust1
Leeds Teaching Hospitals NHS Trust1
Ministry of Defence1

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. Kent and Medway

    AI-generated summary

    David ROOMES · 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

    David ROOMES, who had bipolar affective disorder and a relapse in depressive symptoms, was found deceased in the garage of his address on 14 April 2025, having suspended himself by ligature. The concerns included delays and shortcomings in referral triage, the absence of assessment by a qualified clinician, delays and missed opportunities for clinical review, and potential wider training issues for non-clinical decision makers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure complex risk assessments are undertaken by qualified clinicians

    Wider context from the report

    “(2) David's Dialog+ assessment (an assessment tool, which includes questions to assess risk) was not undertaken by a clinician. I was told in evidence that, given the complexities of David's case, his Dialog+ assessment 'would have benefitted' from assessment by a clinician and that he should have been seen by a qualified clinician at that appointment. I heard evidence that the Band 4 member of staff who undertook the assessment was content with their assessment and the plan that was formulated as a result of it. However, that plan did not include referral to be seen and assessed by a qualified clinician, whereas the evidence I heard was that there was an expectation that David should have been referred to a qualified clinician. While I heard and accepted the evidence that a patient in a similar situation to David would now be able to access the MHT+ team directly, the issue here is one of potential training concerns where non-clinical decision makers are potentially over-confident or may not fully understand the nature and effect of the decisions they are required to make. I was not reassured that this matter has been addressed. ”

    Source location

    David ROOMES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Lina Piroli · 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

    Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.

    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 staff with the expertise required for patients treated in A&E

    Wider context from the report

    “When Lina presented to the Whittington Hospital on the evening of 2 February 2025 it was identified that due to her fractured spine, she would need a bed on an elderly care ward. She was accepted by the medical team but there were no beds available. This meant that she remained in A&E at a time when she was experiencing pain, confusion and delirium due to her injury, infection, pain, pain medication and dementia. I heard that there is guidance on how to treat people with dementia during a hospital admission but that this is simply not achievable in a busy and overcrowded emergency department. Lina was a complex presentation and 93 years old. Whilst Lina received the immediately necessary tests and treatment, she was not seen by the geriatric team (who do not work in A&E) and had delayed access to specialist nurses, robust symptom control measures, regular reviews and coordinated care. She remained in a busy, noisy and frightening environment. It was not until she was moved to a ward that advice was sought on the best management of her spinal fracture. The delay in transferring her to a ward was detrimental to optimising her chances of recovery. I heard evidence that this is not uncommon at the Whittington and is a problem across all London hospitals (and hospitals throughout the UK). When there are no ward beds to transfer patients to, they stay in A&E and A&E is not set up to deliver the care that, particularly elderly and complex medical, patients require. Nursing staff are having to treat double the number of patients that the department is designed to accommodate and patients who require care and treatment outside of their expertise. This means that patients are not receiving the appropriate level of care. ”

    Source location

    Lina Piroli · 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

    Invest in specialist frailty pathways for older people, including frailty same-day emergency care and rapid front-door team input.

    Verbatim wording from the response

    “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 8 December 2025

    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

    Embed elderly care expertise throughout urgent and emergency care.

    Verbatim wording from the response

    “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 8 December 2025

    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 the number of geriatricians and frailty specialists.

    Verbatim wording from the response

    “Regarding specialist care for the elderly, we recognise that older people are particularly vulnerable to long waits and delayed discharges. We are therefore investing in specialist frailty pathways, expanding the community workforce, and embedding elderly care expertise throughout urgent and emergency care. Initiatives such as frailty Same Day Emergency Care units, rapid front-door frailty team input, and integrated neighbourhood teams are designed to ensure older people receive timely, specialist assessment and support. We are also working to increase the number of geriatricians and frailty specialists, and to strengthen collaboration between hospital and community services, so that discharge planning starts earlier and transitions are safer.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 8 December 2025

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    John Francis Heffron · Prevention of Future Deaths report

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

    Report summary

    John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.

    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 establish the nursing qualifications of bank and agency staff permitted to work in the ED

    Wider context from the report

    “(6) It was unclear what steps had been taken by the Trust prior to 12 December 2021 to establish: (i) the nursing qualifications of bank and/or agency staff permitted to work in the ED (ii) whether bank and/or agency staff hold appropriate and current training in resuscitation procedures (iii) whether a suitable induction system was in place to ensure bank and/or agency staff were familiar with the crash call system ”

    Source location

    John Francis Heffron · 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

    Failure to require nursing agencies to supply professionally qualified staff

    Wider context from the report

    “(9) It was unclear whether the Trust’s contractual arrangements with nursing agencies stipulate the requirement for those supplied to (a) be professionally qualified (b) have current training to specified standards and (c) have undergone appropriate induction to the ED. ”

    Source location

    John Francis Heffron · 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

    Existing qualification, training, induction, audit and spot-check arrangements are considered sufficient to ensure temporary ED staff understand emergency procedures.

    Verbatim wording from the response

    “(6) In December 2021 the Trust followed a framework employment checklist for temporary workers on temporary assignments, to establish their qualifications and training prior to them starting work in the ED. This still remains the case. Staff allocated by the preferred provider to work in the EDs should only be staff with prior ED experience. Checks made cover the individual’s qualifications, skills and experience, their DBS status and completion of the Trust’s mandatory and priority training (including refresher training and updating); resuscitation training forms part of this. A CV is received for each candidate in order to verify skills and experience based on previous employment history.”

    Source location

    Response from The Leeds Teaching Hospital
    Page 3 · response
    Published 3 October 2022

    Open published response

  4. Norfolk

    AI-generated summary

    Peggy COPEMAN · 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 Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient CPR-trained staffing for patient transport

    Wider context from the report

    “1. PRAS Response Policy provides that staff escorting patients “are to be fully trained in Basic Life Support (BLS) and are deemed to be competent to apply the techniques when needed. Staff can notice any changes or deteriorating patients and act appropriately in line with BLS training. Starting with Primary assessments followed by secondary assessment then commencing CardioPulmonary Resuscitation (CPR) while waiting for ambulance to arrive ... “ 2. The evidence so far is that during transit, Peggy did not respond when being called or when moving her head and on being noted as being unresponsive, emergency services were not called immediately but calls were initially made to Cygnet and then PRAS. CPR was started on being told to do so by emergency services 3. On attendance by Paramedics it was noted that due to the position of the patient in the back of the van, CPR was ineffective 4. A report has been obtained from a Consultant Cardiologist and General Physician as an expert witness who is of the firm view that the staff transporting Mrs Copeman did not recognise she was in respiratory distress and/or cardiac arrest and that she had effectively died whilst sat between them 5. Only one member of staff out of three had training in CPR 6. An internal investigation (undated) carried out shortly after the incident did not raise concern about these matters 7. A statement provided by the Compliance Manager, PRAS, dated 7 May 2021 concludes that “the ambulance was adequately staffed to enable the journey to be safely carried out”, despite only one member of staff being trained in CPR contrary to PRAS’s own Conveyance Policy ”

    Source location

    Peggy COPEMAN · 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

    Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.

    Verbatim wording from the response

    “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 1 · response
    Published 2 June 2021

    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

    Establish an authorised internal training capacity by qualifying a staff member to train others within the company.

    Verbatim wording from the response

    “1. In response to the concerns raised by the Coroner, Premier Rescue Ambulance Services Ltd., have made a decision that ALL members of staff, including drivers, are to have training in relation to CPR. As a consequence of this decision, ████████ has attended the following courses:”

    Source location

    2021-0182-Response-from-Premier-Rescue-Ambulance-Service-Ltd_Published
    Page 1 · response
    Published 2 June 2021

    Open published response

  5. Birmingham and Solihull

    AI-generated summary

    Joshua Hoole · 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

    Joshua Hoole collapsed and died during an 8-mile, 25 kg loaded march as part of an annual fitness test at Dering Lines Barracks on 19 July 2016. He showed signs of heat illness before collapsing, and was declared deceased despite emergency treatment. The principal concerns included inadequate training and understanding of heat-illness guidance, failure to check or correctly measure the Wet Bulb Globe Temperature, inadequate communication about heat-illness cases, and failure to stop the activity when students became unwell.

    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 medic training and competence to identify heat illness

    Wider context from the report

    “12. Currently MATT2 states the medic on a fitness test is to be MATT3 trained. Given that these medics only receive basic training as per MATT3 consideration needs to be given to have a better qualified medic who can properly identify the signs and symptoms of HI. The inquest was told by those who were MATT3 or team medic trained did not feel confident to diagnose HI and deferred to the CMT. ”

    Source location

    Joshua Hoole · Prevention of Future Deaths report
    Page 4 · 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

    MATT 3-trained First Aid NCOs are considered sufficient to support annual fitness tests, provided heat illness receives adequate focus in annual training.

    Verbatim wording from the response

    “12. Currently MATT2 states the medic on a fitness test is to be MATT3 trained. Given that these medics only receive basic training as per MATT3, consideration needs to be given to have a better qualified medic who can properly identify the signs and symptoms of Heat Illness. The Inquest was told by those who were MATT3 or team medic trained did not feel confident to diagnose Heat Illness and deferred to the Combat Medical Technician (CMT).”

    Source location

    2019-0458-Response-by-MOD
    Page 6 · response
    Published 2 January 2020

    Open published response

  6. West London

    AI-generated summary

    Sophie Bennett · 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

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    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

    Untrained and unqualified care staff

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. There were no, or no adequate, checks and controls by the staff, or by the acting manager, on the keeping of essential documents, including risk assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not qualified clinically, or in the field of mental health, to conduct that audit; • the audit conducted by him (which led to the proposals for change) took only a single day, which was grossly inadequate; • there was no, or no adequate, consultation with the staff, or by the staff with the residents, regarding the substantial changes introduced, and to be made; and • the changes were introduced at a “launch”, with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5. Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: • the need to have in place robust employment procedures; • the matters listed under paragraphs 1 to 4 above; • the appointments of the clinically unqualified ████████ and, later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; • supervision and control of the changes introduced at ████████ instigation; • decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; • communication with other agencies involved in the care of the residents; • the keeping and production (including to the Court, for the purpose of the inquest) of the Board’s own records, communications and contracts; and • knowledge and performance of the Board’s fundamental obligations, including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Wiltshire and Swindon

    AI-generated summary

    Terence Andrew Bennett · 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

    Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.

    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

    Assignment of unqualified staff where qualified staff are required

    Wider context from the report

    “5. Unqualified staff were relied upon in circumstances where qualified staff should have been assigned. ”

    Source location

    Terence Andrew Bennett · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Manchester West

    AI-generated summary

    William Myers · Prevention of Future Deaths report

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

    Report summary

    William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate 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

    Failure to identify complex cases early and assign them to an appropriately qualified psychiatrist

    Wider context from the report

    “Overall, the lingering concern is complex such as this are not identified early enough and managed by an identified and appropriately qualified psychiatrist. There should be a clear delineation of all the clinicians and agencies involved, by way of periodic case conferences with reasons and decisions made being recorded and circulated. The scarcity of inpatient psychiatric beds fuels the concern that complex individuals are being treated in the community rather than controlling the risks they present by having them remain in hospital until such crimes as their condition has been shown to have stabilised. ”

    Source location

    William Myers · 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

    Develop forensic in-reach support for high-risk community patients, including timely advice, risk management and second opinions.

    Verbatim wording from the response

    “In addition we are working with colleagues in the Trust’s forensic services to develop in-reach forensic support in the management of high-risk/MoJ patients in the community, especially in areas such as Central West CMHT with a higher proportion of such patients. This will facilitate improved risk assessment and management, forensic opinion and case conferences.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 3 · response
    Published 14 March 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

    Complete caseload reviews covering patient numbers and complexity within the enhanced community model.

    Verbatim wording from the response

    “The Trust transformational work streams have also identified the importance of the enhanced community model. One key element of this is to complete a caseload review in terms of both number and complexity of patients. We have also identified enhanced supervision of caseloads and review of complexity to ensure that workers are appropriately supported. As part of this work we have also identified the need to reduce consultant only caseloads significantly to ensure that the consultants are fully engaged with the multi-disciplinary teams for discussions on zoning, risk and prioritisation of high risk patients.”

    Source location

    2018-0022-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
    Page 4 · response
    Published 14 March 2018

    Open published response

  9. Manchester North

    AI-generated summary

    Mrs Lindsey Parker · 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 Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure suitably qualified staff manage out-of-hours medical prioritisation of care

    Wider context from the report

    “4. During the course of the evidence, Trust staff were unsure as to what qualifications the 'Hospital at Night' site co-ordinators held. They believed that most, if not all, were likely to be Nurses. My concern here is how/why nurses are deemed suitably qualified to manage out of hours medical prioritisation of care. ”

    Source location

    Mrs Lindsey Parker · 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

    The Hospital at Night model, senior nurse triage and multidisciplinary onsite team provide sufficient out-of-hours prioritisation and care.

    Verbatim wording from the response

    “Salford Royal NHS Foundation Trust adopts the ‘Hospital at Night’ model. This is a clinically driven and patient focused model, which uses both a multi-professional and multispecialty approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes, and supports medical training and service delivery. The Hospital at Night concept proposes that the way to achieve safe clinical care is to have one or more multi-professional teams who have the full range of skills and competences to meet the immediate needs of patients.”

    Source location

    2017-0378-Response-by-Northern-Care-Alliance-NHS-Group
    Page 4 · response
    Published 12 February 2018

    Open published response

  10. Newcastle upon Tyne

    AI-generated summary

    Sheila Mary Hynes · 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

    Sheila Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.

    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

    Assignment of valve remounting to an untrained and inexperienced scrub nurse

    Wider context from the report

    “(1) During Mrs Hynes operation a direction was given to remount the Sorin Carbomedics 23mm mechanical aortic valve on its holder whilst preparations to implant the valve were undertaken. Remounting the valve on its holder is contrary to the manufacturer’s instructions for use. Concerns arising are: a) The rational for departing from the manufacturer's instructions for use was neither discussed nor recorded. b) The primary surgeon and operating team were unaware of the risks of departing from the manufacturer's instructions for use namely potential inverted remount. c) A scrub nurse with neither training nor experience was instructed to remount the valve contrary to the manufacturer's instructions for use. The rational for this direction was neither discussed nor recorded. d) The primary surgeon with overall responsibility for the procedure did not instruct remounting of the valve; There are no recorded discussions with the primary surgeon on this issue. ”

    Source location

    Sheila Mary Hynes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026