Recurring concern

Unreliable staff access to and understanding of safety-critical guidance

First to latest report 3 Dec 2013 — 11 Jan 2023

Reports that mention this concern
13
Times this concern has been raised
13
Stated actions linked to this concern
10

What this concern includes

Includes failures of staff-facing arrangements to provide access to safety-critical guidance or learning material and to verify that relevant staff have accessed, considered and understood it, including computer-based material and associated acknowledgement or comprehension checks.

What is not included
  • Excludes substantive deficiencies in the guidance itself where access or staff understanding is not the reported unsafe condition.
  • Excludes generic staff training, staffing or communication deficiencies that are not specifically tied to access to or understanding of safety-critical guidance.
  • Excludes failures to implement a safety change after staff have reliably accessed and understood the relevant guidance.
  • Excludes named systems, pathways or hazard-specific guidance where that narrower concern provides the more specific supported boundary.

Reports and published responses 13 reports

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

  1. Essex

    AI-generated summary

    John Charles Leyin · 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 Charles Leyin was admitted to Basildon Hospital after suffering a stroke and later died after difficulties with feeding arrangements, including a nasogastric tube being placed into his lung. The concerns included failures to disseminate relevant policy and guidance, weaknesses in training systems, inadequate checks of staff training, and uncertainty about the number of trained staff available for such 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

    Failure to disseminate Trust Policy and NPSA Guidance to all staff

    Wider context from the report

    “(1) There was a failure on the part of the Hospital to ensure the dissemination of Trust Policy and NPSA Guidance to all staff. ”

    Source location

    John Charles Leyin · 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

    Appoint a Risk and Document Control Manager to oversee patient-safety alerts and corporate and clinical policy document control.

    Verbatim wording from the response

    “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

    Source location

    2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 16 December 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Standardise dissemination of clinical guidelines so practice changes are identified centrally and cascaded to all clinical divisions.

    Verbatim wording from the response

    “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

    Source location

    2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 16 December 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a system recording divisional action on patient-safety alerts and enabling prompt escalation of non-compliance.

    Verbatim wording from the response

    “Since 2013 there has been an overhaul of the way in which NPSA Alerts and guidance are disseminated to Trust Staff. The Trust has appointed a Risk and Document Control Manager, who works within the central Clinical Governance Team. As part of their role they have oversight of all NPSA and other alerts, in addition to a role providing oversight of document control, related to Corporate and Clinical policies. It was evident that the process for disseminating clinical guidelines was fragmented. This process has now been standardised to ensure that any change to clinical practice is identified centrally and that this is cascaded to all clinical Divisions. Furthermore, a new system for the management of cascading patient safety alerts is under development, which will evidence action taken by Divisions, so that any non-compliance is addressed quickly and efficiently.”

    Source location

    2014-0563-Response-by-Basildon-Thurrock-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 16 December 2014

    Open published response

  2. County Durham and Darlington

    AI-generated summary

    Richard Philip WHITE · 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

    Richard White was a resident at Hope House who took an overdose of cyclizine and zopiclone on 9 June 2013 and subsequently died from cyclizine toxicity. The concerns were that Hope House’s medication policy was not made known to the prescriber or others involved, was not set out in a protocol or policy statement, and that no such document was 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

    Failure to provide the medication administration and holding policy in a protocol or policy statement to relevant staff

    Wider context from the report

    “1) That the policy of Hope House with regard to the administration and holding by staff of medication was not made known to ████████ when she wrote the prescriptions; 2) That the policy was not provided in a protocol, or policy statement, to ████████, or indeed, ████████ and ████████ 3) That no such protocol or policy statement was available. ”

    Source location

    Richard Philip WHITE · 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

    Responsibility for safeguarding clients regarding prescribed medication lies with GPs, not the organisation.

    Verbatim wording from the response

    “I am writing to your practice on behalf of the 700 Club to remove any ambiguity relating to the storage or administration of medication by our organization. We do not, as a matter of policy, either store medication on behalf of our clients, nor do we administer medication to clients. Prescriptions issued to our clients by your practice should take the above information into account, particularly if that client is vulnerable and there is a concern that the client may use that medication inappropriately (self-harm, selling on). The responsibility for safeguarding clients in regard to prescribed medication lies with GP's.”

    Source location

    2014-0085-Response-by-700-Club2
    Page 1 · response
    Published 28 February 2014

    Open published response

  3. Inner North London

    AI-generated summary

    Agostino COSTA · 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

    Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.

    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 share root cause analysis learning with relevant staff

    Wider context from the report

    “4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

    Source location

    Agostino COSTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026