First reported 26 Feb 2014•Latest report 17 Dec 2025
Definition
What this concern includes
Includes failures to provide, maintain or arrange appropriate supervision for patients in acute medical units, emergency departments and comparable acute hospital assessment areas, including supervision affected by overcrowding, competing demands or inadequate operational arrangements.
Not included
Excludes generic hospital staffing, crowding or resource deficiencies unless they directly result in inadequate supervision of patients in an acute assessment area.
Excludes condition-specific observation systems, such as continuous observation, one-to-one observation, mental-health observations or enhanced-care supervision, where that named system is the more specific supported concern.
Excludes failures of clinical assessment, treatment, handover or escalation where patient supervision is not itself the unsafe condition.
Excludes supervision failures in care homes, prisons, community settings or non-hospital environments.
Reports
5
Distinct published reports
Individual concerns
5
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
15
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 Care3
Cheshire and Wirral Partnership NHS Foundation Trust1
Great Western Hospital1
NHS England1
North West Ambulance Service NHS Trust1
Royal Sussex County Hospital1
University Hospitals Sussex NHS Foundation Trust1
Wirral University Teaching Hospital NHS Foundation Trust1
Ministerial department3
Healthcare site2
NHS trust2
Executive non-departmental public body1
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.
Inner West London
Concerns raised1
Failure to provide safe supervision for patients in overcrowded A&E departments
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Improve hospital flow by reducing waits exceeding 12 hours and progressing towards eliminating corridor care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Wiltshire and Swindon
Concerns raised1
Failure to dynamically provide enhanced supervision for changing patient needs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Maintain acute ward staffing at a 1:8 nurse-to-patient ratio through additional staffing investment.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Operate staffing governance and deployment processes using acuity data, enhanced-care assessments and three-times-daily staffing meetings.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Provide out-of-hours senior nursing support through duty Matron and site-manager roles to adjust staffing and support patient safety.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Review Acute Medical Assessment Unit staffing using the national Safer Nursing Care Tool to inform future staffing models.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Action
Review the enhanced-care policy, documentation and teaching to clarify assessment requirements and supervision levels.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Trial the enhanced-care and ‘Stay in the bay’ approach on three wards, with daily review of assessments, care gaps and education.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Implement and engage all wards in enhanced-care approach rollout informed by trial learning after the trial concludes.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Action
Provide Acute Medical Unit training on multifactorial falls assessment, including risks, information sources and supervision levels.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Action
Recruit Clinical Practice Educators to support ward and assessment-unit training, including enhanced-care training.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local clinical and other leaders are responsible for determining staffing levels and responding to local patient-safety needs.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Insufficient hospital resources and staffing to provide required care and supervision
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Liverpool and the Wirral
Concerns raised1
Failure to provide care and supervision while awaiting assessment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Complete online mental-health training for clinical support workers caring for patients in the Mental Health Unit.
Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Take forward further staff education and training on caring for mental-health patients and appropriate use of the Mental Health Unit.
Stated by Wirral University Teaching Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.
Action
Triage all ambulance-service arrivals on entry, document fit-to-sit rationales, and require verbal handover to the appropriate assessment or triage nurse.
Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Action
Conduct monthly audits of 50 ambulance-service patients and share assessment, observation and triage findings with the Patient Safety and Quality Board.
Stated by Wirral University Teaching Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.
Action
Escalate full Mental Health Unit capacity to the Tactical Commander and shift leader, with defined overnight senior-doctor and shift-leader decision-making, and communicate the process to staff.
Stated by Wirral University Teaching Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
Brighton and Hove
Concerns raised1
Failure to provide appropriate care and supervision in AMU
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures to provide, maintain or arrange appropriate supervision for patients in acute medical units, emergency departments and comparable acute hospital assessment areas, including supervision affected by overcrowding, competing demands or inadequate operational arrangements.
