Recurring concern

Failure to maintain training records that verify staff competence

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First reported 14 Jul 2014•Latest report 13 Nov 2024

Definition

What this concern includes

Includes failures to create, maintain, update, retain or make available records of staff training or competence assurance where the records are needed to verify readiness for safety-critical work, including prisoner-facing contractor staff and nurses undertaking clinical tasks.

Not included

  • Excludes failures to provide training where the training-record process is not itself deficient.
  • Excludes generic clinical, care or workforce record-keeping failures that do not concern records verifying staff training or competence.
  • Excludes records of patient, prisoner or resident care, observations, incidents or other operational activity unless the material issue is verification of staff training or competence.
  • Excludes competence or supervision failures where no training-record or competence-record deficiency is identified.
Reports
11

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
13

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.

HM Prison and Probation Service3
Department of Health and Social Care2
Leeds Teaching Hospitals NHS Trust2
British Sub-Aqua Club1
Carillion (AMBS) Limited1
Devon Partnership NHS Trust1
Dulwich Dive Club1
Essex Partnership University NHS Foundation Trust1
Kingkabs Limited1
NHS England1
Reed Specialist Recruitment Limited1
University Hospitals Birmingham NHS Foundation Trust1
Wandsworth Prison1
Winchester Prison1

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. Exeter & Great Devon

    AI-generated summary

    Elaine JOBE · 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

    Elaine JOBE, an informal voluntary psychiatric patient aged 53, was found hanging in a bathroom at Ocean View on 2 February 2011 after being placed on general hourly observation. Resuscitation and transfer to hospital did not avert her death. Concerns included inadequate records of risk assessments and observations, staff training, and communication of patient status and monitoring responsibilities between shifts.

    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 maintain records of staff training in risk assessments and observation procedures

    Wider context from the report

    “(2)Training Records of training of staff in the making of Risk Assessments and in understanding the meaning of the different Levels of Obs. and implementation of same. ”

    Source location

    Elaine JOBE · 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 recurring risk-management training for registered and unregistered staff, with ward-specific policy training and induction for new staff.

    Verbatim wording from the response

    “Since the sad death of Elaine the trust has reviewed its arrangements and put in to place the following. The Trust requires registered and unregistered staff to be trained in Level 1 Risk Management and all registered staff to be trained to Level 2. Training is repeated every 3 years. Training reports show that all staff have completed Levels 1 and 2 dependent on their registration.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 4 · response
    Published 14 July 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

    Review the inpatient Engagement and Safety Policy, then deliver local ward-based training and collect evidence of completion.

    Verbatim wording from the response

    “3/ The policy is currently under review, once this is completed, (deadline 31st October 2014), local ward-based training will be delivered on the policy and evidence collected.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 5 · response
    Published 14 July 2014

    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

    Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.

    Verbatim wording from the response

    “The Trust has policies, standards and guidance in place for the areas of concern noted in the report. It is not seen as required to introduce new standards, but to ensure the embeddedness of those currently in place. The Trust has several assurance measures in place, but further actions as described below will be put in place to provide additional assurance.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 5 · response
    Published 14 July 2014

    Open published response
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Data last updated 7 September 2026