Recurring concern

Inadequate competence assurance and induction for agency staff

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First reported 8 Jan 2015•Latest report 19 Feb 2026

Definition

What this concern includes

Includes induction, role-specific training, qualification checks and competence assurance for temporary or agency staff assigned clinical or care duties.

Not included

Permanent staff training systems
Agency staffing shortages with no competence deficiency
Individual misconduct after adequate competence assurance

Reports: 27
Individual concerns: 35
Date range: 2015–2026
Stated actions: 69

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 Care3

Ministry of Justice2

NHS England2

Bamford Grange Care Home1

Barchester Healthcare Limited1

Birmingham Community Healthcare NHS Foundation Trust1

Cardiff & Vale University LHB1

Cygnet Behavioural Health Limited1

Darnall Grange Nursing Home1

Essex Partnership University NHS Foundation Trust1

Frimley Health NHS Foundation Trust1

Frimley Park Hospital1

Gloucestershire Health and Care NHS Foundation Trust1

Hampshire and Isle of Wight Healthcare NHS Foundation Trust1

Hc-One Limited1

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.

19 Feb2026
Inner West London
Concerns raised1
1. Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
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 6
1. Action
  Conducted a quality assurance visit verifying ACCT training arrangements and temporary staff completion at HMP Wandsworth.
  Stated by NHS EnglandStated completed
2. Action
  Requested regional commissioning teams to confirm timely access to required joint training, including ACCT, for prison healthcare staff.
  Stated by NHS EnglandStated completed
3. Action
  Obtained assurance from London prison healthcare providers that temporary staff had access to ACCT training arrangements.
  Stated by NHS EnglandStated completed
1. Action
  Obtained further assurance from London prison health providers that systems ensure all staff access required training, including ACCT.
  Stated by NHS EnglandStated completed
2. Action
  Require temporary healthcare staff to complete ACCT training before deployment and record attendance.
  Stated by Oxleas NHS Foundation TrustStated completed
3. Action
  Extend ACCT process coaching and refresher training to non-operational colleagues, including healthcare staff.
  Stated by HM Prison and Probation ServiceStated planned
Respondent positions 2
1. Position
  Existing processes are considered sufficient to ensure temporary prison healthcare staff access required ACCT training.
  Stated by NHS EnglandExisting arrangements considered sufficient
1. Position
  Oxleas is responsible for commenting on ACCT training offered to staff during induction.
  Stated by HM Prison and Probation ServiceRedirects responsibility
AI-generated summary

Rajwinder Singh · 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

Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare staff.

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 mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
Wider context from the report
“(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff. ”
Source location
Rajwinder Singh · 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
Conducted a quality assurance visit verifying ACCT training arrangements and temporary staff completion at HMP Wandsworth.

Verbatim wording from the response
“NHS England undertook a quality assurance visit to the healthcare team at HMP Wandsworth on the 19th March 2026. At that visit, the process was verified and it was confirmed that all temporary staff had undertaken ACCT training, with the exception of two. It was confirmed that the two outstanding members of temporary staff were booked onto ACCT refresher training.”

Source location
Response from NHS England
Page 2 · response
Published 23 February 2026
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
Requested regional commissioning teams to confirm timely access to required joint training, including ACCT, for prison healthcare staff.

Verbatim wording from the response
“In response to the findings of that report and to support national learning, the National Director for Health and Justice requested that regional commissioning teams confirm that there are appropriate arrangements in place to ensure that all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment. Therefore, regional commissioners gained assurance from healthcare providers operating across London prisons, that there were arrangements in place whereby ACCT training was in place for temporary staff working in prison settings.”

Source location
Response from NHS England
Page 2 · response
Published 23 February 2026
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
Obtained assurance from London prison healthcare providers that temporary staff had access to ACCT training arrangements.

Verbatim wording from the response
“In response to the findings of that report and to support national learning, the National Director for Health and Justice requested that regional commissioning teams confirm that there are appropriate arrangements in place to ensure that all staff, including agency and bank staff, have timely access to all joint training, including ACCT, that is necessary for them to undertake their role effectively within the prison environment. Therefore, regional commissioners gained assurance from healthcare providers operating across London prisons, that there were arrangements in place whereby ACCT training was in place for temporary staff working in prison settings.”

Source location
Response from NHS England
Page 2 · response
Published 23 February 2026
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
Obtained further assurance from London prison health providers that systems ensure all staff access required training, including ACCT.

Verbatim wording from the response
“Further assurances were gained by NHS England (London Region) from regional prison health providers in March/April 2026 that there continue to be suitable systems and processes in place to ensure that all staff, including bank and agency staff, have accessed the required training, including ACCT training, to undertake their roles.”

Source location
Response from NHS England
Page 2 · response
Published 23 February 2026
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
Require temporary healthcare staff to complete ACCT training before deployment and record attendance.

Verbatim wording from the response
“It is now mandatory for all temporary healthcare staff to undertake ACCT training. This training is currently provided by the Oxleas NHS Foundation Trust Practice Development Nurse (PDN). Attendance”

Source location
Response from Oxleas NHS
Page 1 · response
Published 23 February 2026
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
Extend ACCT process coaching and refresher training to non-operational colleagues, including healthcare staff.

Verbatim wording from the response
“Whilst HMPPS does not mandate how staff awareness and confidence in delivering ACCT should be maintained, HMP Wandsworth has appointed three dedicated safety floorwalker officers to strengthen oversight of ACCT processes and enhance support for individuals at risk of self-harm or suicide. Their role includes providing direct coaching to ACCT assessors and delivering targeted refresher training to staff to build confidence in key aspects of the process, including identifying risks, triggers and protective factors.”

Source location
Response from HMPPS
Page 1 · response
Published 23 February 2026
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 processes are considered sufficient to ensure temporary prison healthcare staff access required ACCT training.

Verbatim wording from the response
“NHS England’s London regional colleagues have advised that Oxleas NHS Foundation Trust now have a process in HMP Wandsworth to ensure that all staff, permanent and temporary (including agency), have undertaken mandatory ACCT training. At the time of Mr Singh’s death, access to ACCT training was sporadic, due to a shortage of Safer Custody staff available to lead in training. This has since been resolved, with Safer Custody staff now available to deliver ACCT training for healthcare staff on two dates per month. In addition, all members of temporary staff receive an induction before working at HMP Wandsworth.”

Source location
Response from NHS England
Page 1 · response
Published 23 February 2026
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
Oxleas is responsible for commenting on ACCT training offered to staff during induction.

Verbatim wording from the response
“I am aware that this PFD has also been addressed to the Director of Offender Healthcare Operations at Oxleas, who will be able to comment on what is offered to staff during their induction. However, HMP Wandsworth will also extend the aforementioned support to”

Source location
Response from HMPPS
Page 1 · response
Published 23 February 2026
Open published response
8 Feb2026
Essex
Concerns raised1
1. Inexperienced ward staffing for detained children
This report raised 30 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 4
1. Action
  Implement staffing controls requiring appropriately skilled and inducted bank and agency staff, supported by rota review and competency oversight.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Implement enhanced escalation and local induction processes when CAMHS roster requirements or staff competencies are insufficient.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Increase CAMHS staffing capacity and strengthen leadership through additional shift staff, retention premiums, new management and preceptor-support roles, and activity coordinators.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Continue developing CAMHS preceptorship and workforce planning, and use the Mental Health Optimal Staffing Tool across the Trust.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Elise Kay Louise Sebastian · 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

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

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
Inexperienced ward staffing for detained children
Wider context from the report
“1. Mental Health Trust Staff on Longfield Ward: a. Elise was neurodiverse and staff were not trained in Autism b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021. c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised. d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly. e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward. f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated. g. Not all the Trust staff on the ward were trained to use the Oxevision System. h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward. ”
Source location
Elise Kay Louise Sebastian · 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
Implement staffing controls requiring appropriately skilled and inducted bank and agency staff, supported by rota review and competency oversight.

Verbatim wording from the response
“• A review of Rotas undertaken to ensure staffing requirements met including right staff with right training and competency skills.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 2 · response
Published 13 February 2026
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 enhanced escalation and local induction processes when CAMHS roster requirements or staff competencies are insufficient.

Verbatim wording from the response
“• The formulation of an enhanced escalation process when roster requirements are not met. This has been shared across all inpatient services.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 2 · response
Published 13 February 2026
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 CAMHS staffing capacity and strengthen leadership through additional shift staff, retention premiums, new management and preceptor-support roles, and activity coordinators.

Verbatim wording from the response
“• The provision of a retention premium for band 5’s posts”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 2 · response
Published 13 February 2026
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
Continue developing CAMHS preceptorship and workforce planning, and use the Mental Health Optimal Staffing Tool across the Trust.

Verbatim wording from the response
“• Work has continued to develop staff and the CAMHS Preceptorship programme in place, guided practice development framework, led by band 6 practice development role.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 3 · response
Published 13 February 2026
Open published response
18 Nov2025
Northamptonshire
Concerns raised1
1. Failure of care homes to ensure agency carers' suitability, experience and training
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 3
1. Action
  Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.
  Stated by Department of Health and Social CareStated completed
2. Action
  Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.
  Stated by Department of Health and Social CareStated completed
3. Action
  Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.
  Stated by Department of Health and Social CareStated completed
Respondent positions 2
1. Position
  Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
AI-generated summary

Jack Richard BROWN · 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

Jack Richard BROWN, aged 86, was found unresponsive and died at a care home on 26 January 2023 after remaining asleep on a toilet overnight; the post-mortem examination concluded that he died due to ischemic heart disease. The report raised concerns that care agencies supplying staff to care and nursing homes are not required to register with or be regulated by the CQC or another body, creating risks around recruitment, suitability and training of agency carers.

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 of care homes to ensure agency carers' suitability, experience and training
Wider context from the report
“At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. ”
Source location
Jack Richard BROWN · 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
Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.

Verbatim wording from the response
“Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025
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
Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.

Verbatim wording from the response
“The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025
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
Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.

Verbatim wording from the response
“Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector.”

Source location
Response from Department for Health and Social Care
Page 3 · response
Published 1 December 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
Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.

Verbatim wording from the response
“Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 1 December 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
Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.

Verbatim wording from the response
“Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025
Open published response
9 Oct2025
Gateshead and South Tyneside
Concerns raised1
1. Lack of evidenced training requirements for agency nurses
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 2
1. Action
  Reduce reliance on agency nursing staff through workforce measures.
  Stated by Malhotra Care Homes LtdStated completed
2. Action
  Require agencies to provide evidence of mandatory training compliance before nurses work at the Home.
  Stated by Malhotra Care Homes LtdStated completed
AI-generated summary

Pauline Stirling · 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

Pauline Stirling, who had Alzheimer’s disease and Lewy Body Dementia, deteriorated with immobility, reduced nutritional intake and increased frailty before developing worsening pressure damage. She died on 7 March 2024 at Covent House Care Home in Gateshead; the inquest recorded chronic infection due to pressure damage on a background of natural disease. Concerns included inadequate wound monitoring and documentation, inconsistent positional changes and wound care, gaps in staff training, and ongoing record-keeping problems.

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 evidenced training requirements for agency nurses
Wider context from the report
“2. Whilst evidence was provided about the training requirements for full time members of nursing and care staff, to include mandatory full induction and refresher training, I am concerned having heard evidence that to adhere to the ratio of 2 RGNs per shift, agency nurses were regularly utilised, and no evidence about training requirements was provided. ”
Source location
Pauline Stirling · 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
Reduce reliance on agency nursing staff through workforce measures.

Verbatim wording from the response
“The Company has taken steps to reduce its reliance on agency staff. This is demonstrated by an 11.95% decrease in expenditure on agency staff between February 2024, when Mrs. Stirling was a resident in the Home, and October 2025. This reduction has been achieved despite the inflation in wages that have occurred throughout this time period, including the effect of two national minimum wage reviews. In real terms, this would equate to an additional 11-15%. Where agency nurses are needing to be engaged, the Company requires the agency to provide evidence of mandatory training compliance, ensuring that our agency colleagues meet and maintain the professional standards expected from our own employees prior to their arrival at the Home, so to allow the home manager to assess the same.”

Source location
Response from Malhotra Group
Page 2 · response
Published 14 October 2025
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
Require agencies to provide evidence of mandatory training compliance before nurses work at the Home.

Verbatim wording from the response
“The Company has taken steps to reduce its reliance on agency staff. This is demonstrated by an 11.95% decrease in expenditure on agency staff between February 2024, when Mrs. Stirling was a resident in the Home, and October 2025. This reduction has been achieved despite the inflation in wages that have occurred throughout this time period, including the effect of two national minimum wage reviews. In real terms, this would equate to an additional 11-15%. Where agency nurses are needing to be engaged, the Company requires the agency to provide evidence of mandatory training compliance, ensuring that our agency colleagues meet and maintain the professional standards expected from our own employees prior to their arrival at the Home, so to allow the home manager to assess the same.”

Source location
Response from Malhotra Group
Page 2 · response
Published 14 October 2025
Open published response
29 Jul2025
Northumberland
Concerns raised1
1. Failure to ensure agency staff receive and have verified induction
This report raised 7 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 1
1. Position
  The measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.
  Stated by Hill Care GroupNo action considered necessary
AI-generated summary

Joan WHITWORTH · 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

Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.

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 ensure agency staff receive and have verified induction
Wider context from the report
“4. Agency staff - induction I am concerned that an agency member of staff remained in the dining room and was last seen standing next to the alarm bell cord. The care assistant did not intervene immediately when the deceased showed signs of choking and instead sought help. I am further concerned that it could not be confirmed if the agency staff had undergone an induction. ”
Source location
Joan WHITWORTH · Prevention of Future Deaths report
Page 3 · 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 measures described are considered sufficient to satisfy the concerns, so no further safety work is proposed.

Verbatim wording from the response
“We trust that these measures are sufficient to satisfy your concerns.”

Source location
Response from Hill Care Group
Page 3 · response
Published 30 July 2025
Open published response
25 Jul2025
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Lack of risk-assessment training for agency staff
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 6
1. Action
  Develop and roll out a standardised risk-management training programme across mental-health services, including access for long-term community agency staff.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progress
2. Action
  Deliver bespoke risk-management training to community mental-health teams, open to substantive and agency staff.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completed
3. Action
  Agree risk-management training materials with contracted agencies and require signposting before long-term community placements.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progress
1. Action
  Consider additional pre-course risk-management material and pass any identified material to contracted agencies.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated planned
2. Action
  Ask agencies to ensure transient agency staff have maintained risk-management competence.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated planned
3. Action
  Consider ways to better support agency staff to develop risk-management skills.
  Stated by Department of Health and Social CareStated in progress
Respondent positions 2
1. Position
  Providing the full Trust training programme to all agency staff is not feasible because of logistical constraints, transience and additional cost.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustUnable to act
1. Position
  Agencies are responsible for ensuring agency nurses receive appropriate training, while registrants must maintain their own continuing professional development.
  Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustRedirects responsibility
AI-generated summary

Samantha Kate YOUNG · 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

Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.

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 risk-assessment training for agency staff
Wider context from the report
“A. Assessment of the risk that a patient poses to themselves or others is clearly a cornerstone of the work of an NHS Trust dealing with mental health. At the material time there was a lack of any training as to compilation of risk assessments. I was informed by a senior manager of Hampshire and Isle of Wight Healthcare NHS Trust that with the translation of Southern Health NHS Foundation Trust into the new Hampshire and Isle of Wight Healthcare NHS Foundation Trust that issue of training is being addressed. However it emerged at the inquest that there do not appear to be any firm plans to train agency staff. Agency staff form a significant percentage of frontline staff. ”
Source location
Samantha Kate YOUNG · 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
Develop and roll out a standardised risk-management training programme across mental-health services, including access for long-term community agency staff.

Verbatim wording from the response
“As was described in evidence at the inquest, a programme of risk management training is being developed for staff working in mental health services in order that this is standardised across our relatively new organisation. The finer details of the programme and practical elements such as mode and duration of delivery are being worked through, and the intention is to roll the programme out across the organisation in 2026.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 2 · response
Published 28 July 2025
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
Deliver bespoke risk-management training to community mental-health teams, open to substantive and agency staff.

Verbatim wording from the response
“Pending the roll out of our new risk management training programme for our staff, community mental health teams are now receiving bespoke risk management training sessions delivered on a team-by-team basis at their local base. These sessions are open to both agency and substantive staff.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 3 · response
Published 28 July 2025
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
Agree risk-management training materials with contracted agencies and require signposting before long-term community placements.

Verbatim wording from the response
“Work is also underway to agree what training material can be shared with the agencies we contract with in order for them to signpost this to staff who are due to be starting on our longer-term placements. By way of an example, at the end of August 2025, NHS England released an e-learning programme called Staying Safe from Suicide. It is accessible for all staff including those working in the private or voluntary sectors. We intend to make this one of the training modules that the agencies we work with will need to signpost staff to prior to them accepting a community placement with us.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 3 · response
Published 28 July 2025
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
Consider additional pre-course risk-management material and pass any identified material to contracted agencies.

Verbatim wording from the response
“In planning the delivery of our new risk management training programme we will also consider what other ‘pre-course’ material it would be useful for staff to have reviewed. Any additional material identified will be passed to agencies in the same way as above.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 3 · response
Published 28 July 2025
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
Ask agencies to ensure transient agency staff have maintained risk-management competence.

Verbatim wording from the response
“Whilst the above steps will ensure our long-term community agency staff are on a similar footing to Trust employees in respect of risk management training, the situation is admittedly more complex with our more transient agency workforce. These are staff who might have as little contact as attending a ward for a single shift with very short notice and who do not then work for the Trust again for several months. This staff group do not undertake the type of risk formulation and management that our longer-term community agency nurses do. We will be asking the agencies we work with to specifically ensure that these staff have maintained their competence in risk management but need to be upfront about the fact that logistically the other measures described above are not possible to take with this group.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 3 · response
Published 28 July 2025
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
Consider ways to better support agency staff to develop risk-management skills.

Verbatim wording from the response
“I have been informed by the Trust that the position in respect of agency staff and training is a complex one as agency nurses are employed by their agencies and typically do not have access to the in-house training programmes of the NHS Trusts they work at, for a number of logistical and financial reasons. However, given the specific focus on risk management arising from this case and more generally, the Trust is considering ways in which it can better support agency staff to develop in this area.”

Source location
Response from Department for Health and Social Care
Page 1 · response
Published 28 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
Providing the full Trust training programme to all agency staff is not feasible because of logistical constraints, transience and additional cost.

Verbatim wording from the response
“The position in respect of agency staff and training is a complex one. On the one hand, agency nurses are not our employees and often are a very transient part of the workforce. They are employed via their agencies and typically do not have access to the in-house training programmes of the various NHS Trusts they work at for a number of logistical and financial reasons.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 2 · response
Published 28 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
Agencies are responsible for ensuring agency nurses receive appropriate training, while registrants must maintain their own continuing professional development.

Verbatim wording from the response
“By virtue of choosing to work via an agency, their access to training will typically not be through a single training department as would primarily be the case for staff employed by the NHS. Instead, whilst many agencies will provide access to statutory and mandatory training, it is the responsibility of the agency nurses to maintain their continuing professional development beyond this by accessing any additional training they may deem necessary. This can be from a multitude of different routes including accessing private training providers, freely available e-learning programmes or through professional journals, attending conferences/workshops etc. This onus on registrants to take responsibility for remaining competent in their area of practice is clearly set out in the Nursing and Midwifery Council’s Code of Conduct.”

Source location
Response from Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Page 2 · response
Published 28 July 2025
Open published response
22 Jan2025
Manchester South
Concerns raised1
1. Failure to verify agency staff competence to deliver CPR and First Aid
This report raised 8 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
  Bring Approved Premises night shifts in house when the external Double Waking Night Cover contract ends in March 2026.
  Stated by Ministry of JusticeStated planned
2. Action
  Monitor external agency compliance with contractual requirements for HMPPS-standard training, including First Aid, CPR and defibrillator use.
  Stated by Ministry of JusticeStated in progress
AI-generated summary

Nathan Harry SHEPHERD · 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

Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.

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 verify agency staff competence to deliver CPR and First Aid
Wider context from the report
“5. Agency staff were used under a national contract. The evidence before the inquest was that at the time of Mr Shepherd’s death there was no policy for ensuring they could deliver CPR / First Aid. It was part of the national contract that they should be so trained but there were no checks to ensure that this part of the contract was being followed. The evidence at the inquest was that the agency worker in place on the night did not appear able to deliver CPR. ”
Source location
Nathan Harry SHEPHERD · 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
Bring Approved Premises night shifts in house when the external Double Waking Night Cover contract ends in March 2026.

Verbatim wording from the response
“The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.”

Source location
Response from HMPPS
Page 2 · response
Published 22 January 2025
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
Monitor external agency compliance with contractual requirements for HMPPS-standard training, including First Aid, CPR and defibrillator use.

Verbatim wording from the response
“The Double Waking Night Cover contract with external agencies is due to come to an end in March 2026 and thereafter night shifts at Approved Premises will no longer be contracted out and will be brought in house. This will ensure that all staff will be trained in accordance with HMPPS requirements, which includes First Aid, CPR and use of the defibrillator. There are already pilots in place across the country looking to this new arrangement. Where this service is still being delivered by external agencies, it will be part of the contract management process to monitor compliance with the contractual term that requires the agency staff to be fully trained to the standard required by HMPPS.”

Source location
Response from HMPPS
Page 2 · response
Published 22 January 2025
Open published response
17 Jan2025
Worcestershire
Concerns raised1
1. Insufficient induction for agency nurses on completing important documentation
This report raised 5 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

Vauna LEEMING · 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

Vauna Leeming was admitted to hospital after an accidental fall at home that caused a fractured right neck of femur. After surgery, her condition deteriorated, she tested positive for Covid-19, suffered a pulmonary embolism and died in hospital. Concerns included incomplete documentation of anticoagulation and compression-stocking measures, failures to report omissions, and insufficient awareness among employed and agency nurses of these duties.

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 induction for agency nurses on completing important documentation
Wider context from the report
“3) The inquest heard evidence that whilst in its induction to new nurse employees, the Trust emphasises the importance of completing documentation, it is still heavily reliant on agency nurses, for whom it cannot be expected to provide such an induction; ”
Source location
Vauna LEEMING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Oct2024
South Yorkshire (Western)
Concerns raised1
1. Lack of home-specific training for agency staff
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
  Update agency-worker induction with falls protocols, the I STUMBLE tool and post-fall decision-making tool.
  Stated by Hermes Care LtdStated completed
2. Action
  Support new agency staff before shifts and complete existing agency staff attendance at the company’s training sessions.
  Stated by Hermes Care LtdStated in progress
AI-generated summary

Christiana Betty Dawson · 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

Christiana Betty Dawson, known as Betty, was a resident at Darnell Grange who experienced at least ten falls and died in hospital on 19 March 2024 after surgery for a fractured neck of femur and with frailty. The concerns included the management of her falls risk, her return to residential care despite acknowledged difficulties managing that risk, and agency staff not being provided with home-specific training, policies or procedures about moving residents after a fall.

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 home-specific training for agency staff
Wider context from the report
“However, the Court also heard that the nurse involved in moving Betty into bed after her fall on 16 March 2024 was from an agency. The evidence was that agency nurses are not trained on, or provided with, policies and procedures from Darnell Grange and therefore the nurse would not have known the policy was not to move a resident after a fall but to keep them comfortable and preserve their dignity until medical assistance arrived. The Court heard it was presumed from their nursing training they would know not to move a resident after a fall. There is a clear risk of future deaths will occur if agency staff are not provided with home specific training, policies or procedures, not least given that it cannot be said whether the fracture was caused by the fall, or by moving Betty after the fall. ”
Source location
Christiana Betty Dawson · 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
Update agency-worker induction with falls protocols, the I STUMBLE tool and post-fall decision-making tool.

Verbatim wording from the response
“We believe this addresses all the points highlighted by yourself as well as trying to clarify inaccuracies by third parties. We have included documentation including the original MAR Charts received every month, agency nurse induction which has been updated to include instumble and post fall protocol. If you would like a copy of the nurse/team leader attendance sheet this can be provided if required. There are only 2 members of the senior staff team that have not had the revised training session as they were both off sick and will have the training prior to them commencing back at work.”

Source location
Response from Darnell Grange Nursing Home
Page 1 · response
Published 16 October 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
Support new agency staff before shifts and complete existing agency staff attendance at the company’s training sessions.

Verbatim wording from the response
“We believe this addresses all the points highlighted by yourself as well as trying to clarify inaccuracies by third parties. We have included documentation including the original MAR Charts received every month, agency nurse induction which has been updated to include instumble and post fall protocol. If you would like a copy of the nurse/team leader attendance sheet this can be provided if required. There are only 2 members of the senior staff team that have not had the revised training session as they were both off sick and will have the training prior to them commencing back at work.”

Source location
Response from Darnell Grange Nursing Home
Page 1 · response
Published 16 October 2024
Open published response
8 Oct2024
Cornwall and Isles of Scilly
Concerns raised1
1. Lack of proper induction for locum clinicians undertaking extended service cover
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 1
1. Action
  Add catheter-lab pack and preparation content to junior doctor and locum induction programmes.
  Stated by Royal Cornwall Hospitals NHS TrustStated in progress
AI-generated summary

David Charles Martin · 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

David Charles Martin, an 83-year-old man with progressive heart failure, was admitted to hospital, underwent PCI, collapsed later that day, and died in hospital on 17 September 2022. The principal concerns were inadequate induction for a locum doctor unfamiliar with the Trust’s DAPT policy and multiple missed opportunities to identify and act on the fact that he had been prescribed Aspirin only.

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 proper induction for locum clinicians undertaking extended service cover
Wider context from the report
“1) The inquest heard evidence that the locum SHO involved in the care of Mr Martin was 9 days into a 3-4 month period of cover. She had not received any cardiology induction and was unaware of the Trust DAPT policy regarding PCI patients. It was accepted that while it was a challenge to ensure locums who covered 1-2 shifts had a thorough induction, where one was being asked to work in the service for an extended period of time, it was necessary that there was a proper induction process. The inquest heard changes have already been made in this regard. ”
Source location
David Charles Martin · 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
Add catheter-lab pack and preparation content to junior doctor and locum induction programmes.

Verbatim wording from the response
“The Trust is developing a training package for our Roskear Nursing Team and we are in the process of amending our nursing, junior doctors and locum induction programmes to include catheter lab pack and preparation. This is underway and is expected to be completed by 31 December 2024.”

Source location
Response from Royal Cornwall Hospitals
Page 2 · response
Published 10 October 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment

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.6

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

Concerns raised1

Inexperienced ward staffing for detained children

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.4

Concerns raised1

Failure of care homes to ensure agency carers' suitability, experience and training

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.2

Concerns raised1

Lack of evidenced training requirements for agency nurses

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

Concerns raised1

Failure to ensure agency staff receive and have verified induction

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 risk-assessment training for agency staff

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.6

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

Actions described in response 6

Respondent positions 2

Actions described in response 4

Actions described in response 3

Respondent positions 2

Actions described in response 2

Respondent positions 1

Actions described in response 6

Respondent positions 2