Recurring concern

Insufficient district nursing staffing capacity

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First reported 17 Jul 2022•Latest report 27 Jun 2025

Definition

What this concern includes

Includes recurring shortages, under-resourcing, recruitment or retention deficiencies and inadequate staffing resilience specifically affecting district nursing services, including the anchor's under-resourced team and residual District Nursing Service staffing shortages.

Not included

  • Excludes generic healthcare or social-care staffing shortages where district nursing is not the specifically affected service.
  • Excludes district nursing competence, communication, documentation, wound-care or referral failures where staffing capacity is not the shared unsafe condition.
  • Excludes isolated staff absence or workload pressure unless it indicates a continuing district nursing staffing-capacity deficiency.
  • Excludes staffing deficiencies in other community services, hospitals, prisons or care homes.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2022–2025

First to latest report issue date

Stated actions
6

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 Care4
East London NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
London Borough of Newham1
Sunlight Care Group1

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. Norfolk

    AI-generated summary

    Susan Elizabeth CLISSOLD · 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

    Susan Elizabeth CLISSOLD had multiple sclerosis, was registered blind, and received care for a pressure sore and a burn. She was admitted to hospital with symptoms of infection, her condition later deteriorated, and she died on 9 June 2024. The report raised concerns that district nurses sometimes could not attend required appointments because of insufficient staffing, in the context of increasingly complex cases and growing demand for community nursing support.

    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 sufficient community nursing capacity for required patient appointments

    Wider context from the report

    “1. District nurses were required to attend to Mrs Clissold on a weekly basis. On several occasions they did not attend because they did not have sufficient members of the team available. 2. Evidence was heard that individual cases are becoming more complex involving greater input from the community nursing team and there are an increasing number of patients requiring support. 3. Norfolk Community Health and Care NHS Trust has taken steps to try to ensure there are sufficient staff to attend to patients in the community as required, such as by relocating staff on a temporary basis and prioritising patients. 4. However, evidence was heard they are not able to attend to every appointment as required ”

    Source location

    Susan Elizabeth CLISSOLD · 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

    Publish a 10 Year Workforce Plan to support a sufficient and skilled NHS workforce.

    Verbatim wording from the response

    “While the direct responsibility for the quality and number of district nurses sits with local Integrated Care Board and NHS trusts, I would like to assure you that the government recognises the constraints in which the NHS has operated in recent years. That is why this Government will publish a 10 Year Workforce Plan in spring to ensure we have a sufficient and skilled NHS workforce able to provide the right care, at the right time, in the right place.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 14 July 2025

    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

    Responsibility for the number and quality of district nurses rests with local Integrated Care Boards and NHS trusts.

    Verbatim wording from the response

    “Officials within the Department of Health and Social Care have considered these concerns and concluded that the responsibility for the number and quality of district nurses sits with local Integrated Care Boards and NHS trusts. You may find it useful to redirect the Regulation 28 Report to those bodies to get a full and comprehensive response on the matters you have raised.”

    Source location

    Response from Department for Health and Social Care
    Page 1 · response
    Published 14 July 2025

    Open published response
  2. East London

    AI-generated summary

    Omar Abdi Ahmed · 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

    Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.

    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

    Under-resourcing of the district nursing team

    Wider context from the report

    “2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment. ”

    Source location

    Omar Abdi Ahmed · 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

    Staff the dressing clinic with a substantive band 6 nurse under senior Trust community district nursing line management.

    Verbatim wording from the response

    “12. Since the sad death of Mr Ahmed, some further changes were introduced to the dressing clinic. It is now staffed by a substantive band 6 nurse (as opposed to temporary staff) whose clinical and professional line management is provided by senior nursing within the Trust’s Community District Nursing Team. I expect this will improve the accountability of clinical staff on the team as well as allow them to receive more consistent supervision and improve clinical skills and enhance curiosity.”

    Source location

    Response from ELFT
    Page 4 · response
    Published 31 July 2024

    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

    Implement a dressing-clinic standard operating procedure providing 30-minute service-user appointment slots instead of 10-minute slots.

    Verbatim wording from the response

    “13. On 24 July, a new standard operating procedure was put into place for dressing clinic staff. The key change is that the time slots allocated to attend to service users has increased from 10 minutes to 30 minutes. It is anticipated that the provision of additional time to complete work should improve care planning and allow more meaningful communications with other services as well as improve staff morale.”

    Source location

    Response from ELFT
    Page 4 · response
    Published 31 July 2024

    Open published response
  3. Manchester South

    AI-generated summary

    John Richard Hartey · 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 Richard Hartey was found dead at home on 20 October 2023. His death was attributed to congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus, with acute bronchitis and transplant immunosuppression contributing. The court heard concern that a national shortage of District Nurses and Community Specialist Practitioners could delay patients being seen in accordance with their needs.

    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 District Nursing and Community Specialist Practitioner capacity to see patients in accordance with their needs

    Wider context from the report

    “It is a matter of concern that a national shortage of District Nurses / Community Specialist Practitioners can lead to a delay in patients being seen in accordance with their needs. ”

    Source location

    John Richard Hartey · 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

    Move toward a neighbourhood health service by delivering more care in local communities and shifting resources over time to primary and community services.

    Verbatim wording from the response

    “We have set out a clear commitment to move to a neighbourhood health service, with more care delivered in local communities to spot problems earlier, this includes over time shifting resources to primary care and community services. In the longer term, we are committed to training the staff the NHS needs to be there for patients when they need it.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 31 May 2024

    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

    Train the staff the NHS needs to provide care when patients need it.

    Verbatim wording from the response

    “We have set out a clear commitment to move to a neighbourhood health service, with more care delivered in local communities to spot problems earlier, this includes over time shifting resources to primary care and community services. In the longer term, we are committed to training the staff the NHS needs to be there for patients when they need it.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 31 May 2024

    Open published response
  4. Manchester South

    AI-generated summary

    Elizabeth Roberts · 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

    Elizabeth Roberts was severely frail and bedbound and developed a large sacral sore with sepsis, followed by congestive cardiac failure. She died at Tameside General Hospital on 19 May 2023; the principal concern was residual staffing shortages in the District Nursing Service, which the Trust was unable to resolve without a national change of approach.

    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

    Residual staffing shortages in the District Nursing Service

    Wider context from the report

    “(1) Despite a number of measures being undertaken by Tameside and Glossop Integrated Care and NHS Foundation Trust, the Inquest heard that there are residual staffing shortages in the District Nursing Service which the Trust is unable to resolve without a change of approach nationally. ”

    Source location

    Elizabeth Roberts · 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

    Increase NHS nurse numbers, including community nursing capacity, to address staffing shortages.

    Verbatim wording from the response

    “Nationally, we have taken steps to increase nurse numbers and in September 2023 we met our commitment to delivering 50,000 more nurses working in the NHS compared with September 2019.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 8 January 2024

    Open published response
  5. Manchester South

    AI-generated summary

    Darren Jones · 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

    Darren Jones, who had severe learning disabilities, a long-term catheter and chronic kidney disease, was admitted to Stepping Hill Hospital after unsuccessful catheter changes in the community and Emergency Department. He deteriorated despite treatment for sepsis and died at the hospital on 22 October 2021. The concerns included pressures on community district nursing services, insufficient recognition of his learning difficulties and support needs in hospital, a dispute between Local Authorities affecting respite care and catheter-care training, and the absence of a commissioned LeDeR review.

    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 District Nursing Team staffing capacity for caseload demand

    Wider context from the report

    “1. The Inquest heard that delivering care in the community to Mr Jones in relation to his catheter care was impacted by the significant demands on the District Nursing Team due to their staffing levels against their caseload. The evidence was that the District Nursing Teams were under significant pressure which impacted the support and care they could deliver; ”

    Source location

    Darren Jones · 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 case findings were attributed to individual practice and awareness rather than District Nursing Service pressures, although wider pressures may have contributed.

    Verbatim wording from the response

    “In response to the general question of pressures within the District Nursing Service, there are pressures across the system including district nursing services. However, the findings in this case were identified to be around individual practice and awareness as opposed to being due to pressures. That said, it can be realistically accepted that wider pressures may have had an impact.”

    Source location

    Response from NHS Greater Manchester
    Page 2 · response
    Published 27 September 2022

    Open published response
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Data last updated 7 September 2026