Recurring concern

Insufficient emergency-department staffing capacity for safe patient care

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First reported 15 Apr 2014•Latest report 17 Dec 2025

Definition

What this concern includes

Includes recurring deficiencies in the number, availability, deployment, cover or resilience of doctors, nurses and other staff needed to care for, monitor and manage Emergency Department patients, including shortages during busy periods and staffing levels insufficient for demand.

Not included

Excludes generic healthcare staffing shortages outside emergency departments unless the assertion explicitly concerns emergency-department staffing capacity.
Excludes agency-staff use, fatigue, competence or retention concerns unless they directly establish insufficient emergency-department staffing capacity for safe patient care.
Excludes emergency-department space, overcrowding, bed-flow and general operational-pressure deficiencies where staffing capacity is not the shared unsafe condition.
Excludes one-off staff absences or isolated clinical omissions where no continuing emergency-department staffing-capacity problem is asserted.

Reports: 18
Individual concerns: 20
Date range: 2014–2025
Stated actions: 64

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care7

Betsi Cadwaladr University LHB4

NHS England4

Sherwood Forest Hospitals NHS Foundation Trust2

Aneurin Bevan University LHB1

Chelsea and Westminster Hospital NHS Foundation Trust1

Conwy County Borough Council1

Denbighshire County Council1

Flintshire County Council1

Greater Manchester Health and Social Care Partnership1

Milton Keynes University Hospital1

Royal College of Emergency Medicine1

Royal College of Paediatrics and Child Health1

Royal Free Hospital1

Royal Stoke University Hospital1

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.

10 Feb2023
Manchester South
Concerns raised2
1. Delays in Emergency Department senior clinician review due to insufficient senior medical staffing
2. Delays in Emergency Department clinician review due to patient volume and insufficient staff availability
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.
Respondent positions 2
1. Position
  NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Celia Sanderson · 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

Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

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
Delays in Emergency Department senior clinician review due to insufficient senior medical staffing
Wider context from the report
“2. The inquest heard that amongst the challenges faced was a shortage of ED consultants and ED middle grade doctors. Mrs Sanderson’s time at the hospital included late evening and the early hours of the morning. The inquest heard that across the NHS during these hours the number of staff at these grades in an ED is significantly reduced. Historically that had been a quieter period however demands on ED meant that was no longer the case. As a consequence senior reviews of patients were further delayed. An earlier review by a senior clinician was likely to have identified her as a potential silver trauma case and ensured she was moved to a trauma centre for appropriate treatment before she began to deteriorate; ”
Source location
Celia Sanderson · 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
Delays in Emergency Department clinician review due to patient volume and insufficient staff availability
Wider context from the report
“1. Demands on the Emergency Department due to the volume of people waiting to be seen meant that Mrs Sanderson had a long wait for a clinician review far outside the expected target time. The inquest heard evidence that delays such as hers were common throughout that period and were due to the volume of people attending and staff available to deal with them; ”
Source location
Celia Sanderson · 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
NHSE and local integrated care bodies are responsible for addressing the concerns about treatment at Wythenshawe Hospital.

Verbatim wording from the response
“Your report raises concerns about the treatment provided at Wythenshawe Hospital, Manchester University NHS Foundation Trust. I understand that NHS England (NHSE) have written to you to address these concerns, including information from Greater Manchester Integrated Care and the Integrated Care Board on the action taken locally. This includes NHS Greater Manchester’s action plan to respond to urgent and emergency care demand pressures, as well as their Major Trauma Network. This network provides care to patients who have sustained major trauma injuries; partners work collaboratively to ensure trauma is recognised and treated appropriately. Learning from the investigation into Ms Sanderson’s death has been used to improve practice across the network.”

Source location
Response from DHSC
Page 1 · response
Published 24 February 2023
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
Greater Manchester Integrated Care provides the relevant services, while its Integrated Care Board decides commissioned health services.

Verbatim wording from the response
“In order to be able to respond to your Report, NHS England has engaged with Greater Manchester Integrated Care (NHS GM) who is the provider of the healthcare services in question, and the Integrated Care Board (ICB) who is responsible for making decisions about commissioned health services across Greater Manchester NHS England’s response to your Report is based on our informed discussions with these two organisations.”

Source location
Response from NHS England
Page 1 · response
Published 24 February 2023
Open published response
23 Oct2021
Manchester South
Concerns raised2
1. Lack of on-site emergency department consultant cover from late evening until morning
2. Insufficient senior emergency department doctor staffing at night
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.
AI-generated summary

Margaret Kinsey · 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

Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.

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
Lack of on-site emergency department consultant cover from late evening until morning
Wider context from the report
“2. The inquest heard that there was a shortage of ED consultants across the NHS which led to these challenges in relation to staffing ED and that it was not uncommon for staffing of ED to be based on there being no on site consultant cover in ED from late evening until the morning. ”
Source location
Margaret Kinsey · 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
Insufficient senior emergency department doctor staffing at night
Wider context from the report
“1. The inquest heard that due to the time of her arrival in the Emergency Department on 11th December 2020 consultants were not on site. The most senior doctors available were middle grade and the number available at that time of night was significantly reduced. As a consequence the evidence was that supervision and support of junior doctors was very difficult given the demands on the middle grade doctors on site. This was exacerbated by the fact that on the evening Mrs Kinsey was admitted the FY doctors had just rotated. The FY2 who saw her had very limited post qualification experience of Emergency Medicine. The inquest heard that particularly at night time support and supervision of FY ED doctors presents significant challenges across the NHS in relation to patient care. ”
Source location
Margaret Kinsey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Jul2021
Gwent
Concerns raised1
1. Inadequate staffing levels for the full range of Emergency Department duties
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 3
1. Action
  Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.
  Stated by Aneurin Bevan University LHBStated completed
2. Action
  Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.
  Stated by Aneurin Bevan University LHBStated completed
3. Action
  Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.
  Stated by Aneurin Bevan University LHBStated in progress
Respondent positions 1
1. Position
  Nurse staffing levels were adequate and did not prevent neurological observations.
  Stated by Aneurin Bevan University LHBDisputes the concern
AI-generated summary

Valmai Ann WEST · 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

Valmai West suffered falls on 11 and 16 January 2020, was admitted to hospital after fracturing her pubic ramus, and was later found unresponsive with an extensive subdural haemorrhage. She died at the Royal Gwent Hospital on 22 January 2020. The concern identified was that Emergency Department staffing levels may have contributed to observations not being performed in accordance with hospital protocol and NICE guidance, potentially putting future patients at risk.

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
Inadequate staffing levels for the full range of Emergency Department duties
Wider context from the report
“During the course of the inquest, consideration was given to the clinical decisions made in the Emergency Department of the Royal Gwent Hospital. I concluded that there was no evidence that Mrs West was displaying signs that would alert the staff to a possible intracranial bleed. However in evidence Dr ████████ Consultant in Emergency Medicine, acknowledged that the staff had not followed hospital protocol or the NICE guidance in relation to the frequency with which observations should be performed. Dr ████████ assessment of the situation was that this was probably caused by inadequate staff numbers to undertake the full range of duties required. She further stated that this is a frequent and ongoing problem in the Emergency Department. Whilst this did not influence the outcome for Mrs West I am concerned that this may put the lives of future patients at risk. ”
Source location
Valmai Ann WEST · 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
Complete a review of Emergency Department nurse staffing levels following the Regulation 28 Report.

Verbatim wording from the response
“Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.”

Source location
2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 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
Complete an in-depth review of Emergency Department nurse staffing levels at Grange University Hospital, considering increased demand and relevant staffing guidance.

Verbatim wording from the response
“I thought it would be helpful to share that an in-depth review of nurse staffing levels for the Emergency Department (ED) at the Grange University Hospital was commissioned as a result of the early opening of the hospital and in light of increased patient demand. This has been undertaken by the”

Source location
2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 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
Undertake a review of Emergency Department medical staffing alongside the nurse staffing review.

Verbatim wording from the response
“Senior Nurse Manager for ED and the Assistant Head of Nursing, supported by the Deputy Director of Nursing. The assessment is based on RCN Guidance, RCEM Guidance, Nurse Staffing Levels (Wales) Act 2016 and, importantly, professional judgement. A similar review of medical staffing is also being undertaken.”

Source location
2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 2 · response
Published 15 July 2021
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
Nurse staffing levels were adequate and did not prevent neurological observations.

Verbatim wording from the response
“Following receipt of the Regulation 28 Report a review of the nurse staffing levels was undertaken by the Senior Nurse Manager of the Emergency Department. I can confirm nurse staffing levels at the index time were appropriate and adequate and as per the roster for the area the patient was cared for. The staffing levels would not have impacted on the ability to undertake neurological observations.”

Source location
2021-0239-Response-from-Aneurin-Bevan-University-Health-Board_Published
Page 1 · response
Published 15 July 2021
Open published response
13 Jul2020
Manchester South
Concerns raised1
1. Failure to maintain adequate staffing by nurses trained to work in the emergency department
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.
Actions described in response 2
1. Action
  Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.
  Stated by Department of Health and Social CareStated planned
2. Action
  Work with service colleagues, NHSE/I and Health Education England to improve nurse staffing, including agreeing further support with the Stockport Trust HR lead.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

John Cheetham · 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 Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

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 adequate staffing by nurses trained to work in the emergency department
Wider context from the report
“4. The inquest was also told that a shortage of nurses nationally trained to work in ED had meant that the unit was short staffed on the night he fell and suffered a catastrophic injury. ”
Source location
John Cheetham · 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
Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.

Verbatim wording from the response
“In relation to the matter of concern in your report about a shortage of nurses trained to work in emergency departments, I would like to assure you that ensuring the NHS has the staff it needs, especially nursing staff who are also suitable bedrock of the NHS and care system, is and will remain, a priority for this Government. That is why we made our manifesto pledge to deliver 50,000 more nurses in our NHS by 2025, which we will achieve through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 3 · response
Published 1 October 2020
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
Work with service colleagues, NHSE/I and Health Education England to improve nurse staffing, including agreeing further support with the Stockport Trust HR lead.

Verbatim wording from the response
“Nurse recruitment and retention is a priority for the Greater Manchester system and work is underway with Greater Manchester service colleagues, NHSE/I and Health Education England, in order to maximise opportunities for improved nurse staffing in all localities. The GMHSCP executive workforce lead is planning to meet with the Stockport Trust HR lead over the next month and will agree any further support that is required.”

Source location
2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
Page 3 · response
Published 1 October 2020
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
Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.

Verbatim wording from the response
“It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.”

Source location
2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 1 · response
Published 1 October 2020
Open published response
26 Sep2019
Milton Keynes
Concerns raised1
1. Lack of adequate Emergency Department staffing
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Recruit nursing staff through open days and ongoing advertising.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progress
2. Action
  Train and employ eight advanced nurse practitioners across Emergency Department and Acute Medicine pathways.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated planned
3. Action
  Increase the Emergency Department senior house officer establishment.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
1. Action
  Redeploy staff from other hospital areas to mitigate Emergency Department staffing gaps.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
2. Action
  Engage staff-bank and agency workers, including an Emergency Department staff-bank financial supplement, to mitigate staffing gaps.
  Stated by Milton Keynes University Hospital NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  Staff shortages per se were not considered a significant factor in the shortcomings in care or the June 2019 incident.
  Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concern
1. Position
  Established staffing levels, daily redeployment, bank and agency staffing, and local resource decisions were considered sufficient to mitigate staffing risks.
  Stated by Milton Keynes University Hospital NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

John SHROSBREE · 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 SHROSBREE was admitted to Milton Keynes University Hospital on 4 June 2019 seriously unwell with high potassium, and later suffered a hyperkalaemic cardiac arrest, hypoxic brain damage and died on 11 June 2019. The concerns included failures to review observations, escalate care, monitor him appropriately and start treatment promptly, with staff shortages identified as a principal concern.

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
Lack of adequate Emergency Department staffing
Wider context from the report
“My concern is that during the evidence it became clear that the problems encountered in the Emergency Department on 4th June 2019 were mainly brought about by staff shortages. I was told that staff shortages occur on a daily basis and I believe that as a result lives of this citizens of Milton Keynes are being put at risk and the problem should be addressed as a matter of urgency. ”
Source location
John SHROSBREE · 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
Recruit nursing staff through open days and ongoing advertising.

Verbatim wording from the response
“Vacancies (against our agreed establishment) occur for several reasons over and above the number of leavers exceeding those coming into post: for example, parental leave and secondment. In nursing, vacancy rates tend to peak in the late summer / early autumn and reduce as new graduates are available to start work in band 5 entry level posts. Recruitment to nursing roles is ongoing with active and engaging open days in place, in”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 2 · response
Published 1 October 2019
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 and employ eight advanced nurse practitioners across Emergency Department and Acute Medicine pathways.

Verbatim wording from the response
“This variation from peer median represents a relatively small emergency nurse practitioner (ENP) workforce in Milton Keynes. ENPs typically work in the ‘ED minors’ environment, and in many departments ENPs have replaced a significant part of the non-consultant medical workforce. We do not consider that there is any material difference in nurse staff numbers attending to the needs of patients in the majors and resuscitation environments (where Mr Shrosbree was looked after). The Trust continues to develop the non-medical workforce in the Emergency Department and has recently confirmed plans to train and employ eight advanced nurse practitioners focusing on the emergency care pathway (ED and Acute Medicine).”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 3 · response
Published 1 October 2019
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 Emergency Department senior house officer establishment.

Verbatim wording from the response
“Role | Establishment / Funded Posts | Vacancy Rate Band 8A (Matron) | 2.0 | 0% Band 7 (Senior Sister / Charge Nurse) | 9.54 | 10% Band 6 (Sister / Charge Nurse) | 16.51 | 3% Band 5 (Staff Nurse) | 47.39 | 27% (17% in June 2019) Band 2 (Healthcare Assistant) | 24.8 | 21% Consultant | 10 | 0% Middle Grade / Registrar | 16 | 6% ENP (Emergency Nurse Practitioner) | 4.89 | 0% Senior House Officer | 15 | 13% (establishment increased in August 2019)”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 2 · response
Published 1 October 2019
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
Redeploy staff from other hospital areas to mitigate Emergency Department staffing gaps.

Verbatim wording from the response
“Where there is a gap on a given shift between staffing establishment and staff on duty, several things are put in place to mitigate risk. These include:”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 3 · response
Published 1 October 2019
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
Engage staff-bank and agency workers, including an Emergency Department staff-bank financial supplement, to mitigate staffing gaps.

Verbatim wording from the response
“Where there is a gap on a given shift between staffing establishment and staff on duty, several things are put in place to mitigate risk. These include:”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 3 · response
Published 1 October 2019
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
Staff shortages per se were not considered a significant factor in the shortcomings in care or the June 2019 incident.

Verbatim wording from the response
“staff shortages per se were a significant factor.”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 2 · response
Published 1 October 2019
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
Established staffing levels, daily redeployment, bank and agency staffing, and local resource decisions were considered sufficient to mitigate staffing risks.

Verbatim wording from the response
“We have invested heavily in clinical staffing levels over the past six years and have measures in place day-to-day in order to ensure that the risk associated with any sub-optimal staffing numbers is spread appropriately across the organisation such that ‘sub-optimal’ does not equate to ‘unsafe’.”

Source location
2019-0260-Response-by-Milton-Keynes-University-Hospital-Trust
Page 2 · response
Published 1 October 2019
Open published response
17 May2017
North Wales (East and Central)
Concerns raised1
1. Failure to maintain adequate emergency department staffing
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 3
1. Action
  Recruit and increase funded nursing and medical staffing at Ysbyty Glan Clwyd ED.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
2. Action
  Align senior medical staffing hours with peak ED demand.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
3. Action
  Recruit medical staff and revise staffing rotas at Ysbyty Maelor Wrexham ED.
  Stated by Betsi Cadwaladr University LHB and Conwy County Borough Council and Denbighshire County Council and Flintshire County Council and Welsh Ambulance Services NHS Trust and Wrexham County Borough CouncilStated in progress
AI-generated summary

Lilly Baxandall · 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

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.

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 adequate emergency department staffing
Wider context from the report
“Following an inquest which concluded in January 2014 I issued a regulation 28 report in which I expressed concerns regarding the handover of patients at an emergency department which resulted in "unacceptable delays with patients being kept waiting for long periods in ambulances and ambulance resources consequently being unavailable for allocation to other calls". In September 2014 I issued a further regulation 28 report raising similar concerns regarding delays. In November 2015 I issued a regulation 28 report concerning delays in an emergency department which "were excessive and inadequate action was taken by the Health Board to overcome the problems of staff shortages leading to long waiting times and risks to patients". In December 2015 I issued a regulation 28 report expressing concerns regarding the throughput of patients in hospital and Delayed Transfer of Care. In August 2016 I issued a regulation 28 report regarding a delay in admission to hospital via the emergency department which formed part of a cumulative delay in diagnosis and treatment which prevented a patient having the best prospect of a successful outcome. In January 2017 I issued a regulation 28 report expressing a concern “that there are invariably delays in admissions to hospital as there are insufficient beds available to accommodate all admissions”. In March 2017 I issued a regulation 28 report expressing concern that there “continue to be substantial delays in the handover of patients particularly as a result of problems in patient flow resulting in an inability to admit patients who require treatment” Despite the above reports issued to the Health Board and Ambulance Service the problems of ambulance delays/handover delays/bed blocking/patient flow and delayed transfer of care continue to the present day and patients’ lives are being placed at risk as a result. It is very well recognised that the issues are multifactorial and will require multi agency cooperation for improvements or change to be made, however unless services and resources are made available or working practices altered to facilitate such change then it is inevitable that future deaths will occur which might have otherwise been preventable. ”
Source location
Lilly Baxandall · 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
Recruit and increase funded nursing and medical staffing at Ysbyty Glan Clwyd ED.

Verbatim wording from the response
“• On-going recruitment of nursing and medical staff is a key focus. This has resulted in an increase in the funded nursing establishment in ED from 56 WTE to 94 WTE, and an increase in funded medical staff posts to double the posts from 4 to 8 full time Consultants and from 5 to 8 middle grade senior doctors. It will take time to attract and recruit substantive staff to all posts although recent recruitment campaigns for senior medical staff have met with success. It is anticipated that the Consultant and senior middle grade doctor posts will all be filled with substantive appointments by the end of 2017. Until this time, the service is employing locum medical staff to provide as much service cover and continuity of care as possible.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
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
Align senior medical staffing hours with peak ED demand.

Verbatim wording from the response
“• The service is also working towards better matching senior medical staff working hours with times of peak patient demand. The aim is to have the Consultant late day shift extended from 18.00hrs to 22.00hrs and have a second Consultant working until 9pm Monday to Friday”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
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
Recruit medical staff and revise staffing rotas at Ysbyty Maelor Wrexham ED.

Verbatim wording from the response
“• The recruitment of medical staff is ongoing to improve cover of the medical rota from August 2017 at middle grade and SHO level. There are 2 wte Consultant vacancies currently covered with locum Consultants. There is a focused campaign of work ongoing to recruit to these key posts on a permanent basis.”

Source location
2017-0160-Response-by-University-Health-Board
Page 7 · response
Published 17 August 2017
Open published response
24 Oct2016
West London
Concerns raised1
1. Insufficient Emergency Department staffing for treating suspected sepsis in accordance with national or local policy
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.
AI-generated summary

Hunter Jack Macmillan · 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

Hunter Jack Macmillan was taken to the Emergency Department at West Middlesex Hospital after being booked into the Urgent Care Centre, but was not triaged for over 45 minutes as his condition deteriorated. The report raised concerns that staffing levels were insufficient to follow national or local policies for treating suspected sepsis.

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 Emergency Department staffing for treating suspected sepsis in accordance with national or local policy
Wider context from the report
“Staffing levels in the Emergency Department were not sufficient to be able to follow national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis. ”
Source location
Hunter Jack Macmillan · Prevention of Future Deaths report
Page 1 · concerns
Open source report
15 Apr2014
Inner West London
Concerns raised1
1. Insufficient A&E cover by clinicians able to secure airways via emergency surgical tracheotomy
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 2
1. Action
  Review Emergency Departments and senior-staff availability for emergency airway skills across London.
  Stated by NHS EnglandStated completed
2. Action
  Implement increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.
  Stated by NHS EnglandUnable to act
1. Position
  Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Desiree Harmony Falvo · 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

Desiree Harmony Falvo developed severe breathing difficulties after a procedure and was transferred to hospital in extremis. Difficulties securing her airway led to cardiac arrest and hypoxic brain injury, and she subsequently died in intensive care. The concerns were insufficient on-site emergency surgical tracheotomy expertise in some A&E departments and the adequacy of training and confidence of clinicians expected to secure airways.

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 A&E cover by clinicians able to secure airways via emergency surgical tracheotomy
Wider context from the report
“(1) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy, ”
Source location
Desiree Harmony Falvo · 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
Review Emergency Departments and senior-staff availability for emergency airway skills across London.

Verbatim wording from the response
“Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Implement increased senior doctor presence in A&E departments, including 24/7 consultant cover in Major Trauma units and extended consultant or senior trainee cover elsewhere.

Verbatim wording from the response
“Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed whereby all Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Immediate resident ENT surgeon cover in every A&E is impractical because there are insufficient experienced ENT surgeons.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 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
Acute Trusts providing A&E are responsible for managing airway-cover risks through general training and timely access to specialist expertise.

Verbatim wording from the response
“There are insufficient experienced ENT surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle cricothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained.”

Source location
2014-0171-Response-by-NHS-England
Page 1 · response
Published 15 April 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Delays in Emergency Department senior clinician review due to insufficient senior medical staffing

Delays in Emergency Department clinician review due to patient volume and insufficient staff availability

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Lack of on-site emergency department consultant cover from late evening until morning

Insufficient senior emergency department doctor staffing at night

Concerns raised1

Inadequate staffing levels for the full range of Emergency Department duties

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to maintain adequate staffing by nurses trained to work in the emergency department

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.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of adequate Emergency Department staffing

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to maintain adequate emergency department staffing

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.3

Respondent positions 2

Actions described in response 3

Respondent positions 1

Actions described in response 2

Respondent positions 1

Actions described in response 5

Respondent positions 2

Actions described in response 3