Recurring concern

Unreliable hospital system access for temporary clinical staff

First to latest report 23 Jul 2014 — 5 Dec 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
1

What this concern includes

Includes failures of hospital or healthcare IT access arrangements for agency nurses, locum doctors and comparable temporary clinical staff where inadequate, unavailable or unreliable individual access impairs requesting, reviewing, recording or acting on clinically relevant information.

What is not included
  • Excludes generic IT outages or login problems not specifically affecting temporary clinical staff performing clinical work.
  • Excludes failures of clinical competence, induction, supervision or staffing capacity where system access is not the unsafe condition.
  • Excludes inaccurate or incomplete clinical records where access and attribution controls were reliable.
  • Excludes access failures involving permanent staff unless the report explicitly links them to the same temporary-clinical-staff access arrangement.

Reports and published responses 5 reports

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

  1. Manchester South

    AI-generated summary

    Alan Paul Peet · 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

    Alan Paul Peet, who was quadriplegic following an accidental fall, was admitted to hospital after his condition deteriorated at Acer Mews Care Home on 26 July 2025. He was found to be septic, possibly due to bronchopneumonia, and died at Tameside General Hospital on 28 July 2025. Concerns included inadequate observation and record-keeping, lack of clear management oversight of tracheostomy-trained nursing cover, and agency staff lacking access to electronic systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide agency nurses with individual login rights to electronic care and medication systems

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”

    Source location

    Alan Paul Peet · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Jacob · 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

    Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.

    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

    Login issues for locum doctors working at the Trust

    Wider context from the report

    “5. The risk of continuing Login issues when Locum doctors are working at the Trust ”

    Source location

    Jacob · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The locum doctor’s access was available; the identified problem was use of a colleague’s credentials rather than a login failure.

    Verbatim wording from the response

    “5. The risk of continuing Login issues when Locum doctors are working at the Trust”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 3 August 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

    Established Trust and out-of-hours processes ensure locum doctors receive necessary IT access before commencing shifts.

    Verbatim wording from the response

    “There is a Trust system which has been in place for several years to ensure locum doctors have access to the relevant and necessary IT. This system was in place prior to, and at the time of Jacob’s admission to hospital. Dr ████████, Executive Medical Director is assured that the availability of a log-in was not the issue in Jacob’s case, but the staff member, for reasons which are unclear, chose to use a colleague’s log-in details, rather than their own, which had been issued to them by the Trust in January 2014.”

    Source location

    2021-0259-Response-from-Doncaster-and-Bassetlaw-Teaching-Hospitals-NHS-Foundation-Trust_Published
    Page 6 · response
    Published 3 August 2021

    Open published response

  3. Shropshire, Telford and Wrekin

    AI-generated summary

    Mark Richard HINTON · 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

    Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.

    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 system access for agency nurses and locum doctors

    Wider context from the report

    “(2) System failures. a) The system did not require or mandate the person who requested blood tests, specifically in this case a D-Dimer test, to record that request or the reason for it. There was no alert system which would have alerted the final decision maker of that request. At that time a health care assistant, staff nurse or doctor could have requested the tests. Only a doctor may do so now. b) The evidence indicated that agency nurses and locum doctors did not have access to the hospital systems in particular the “review” system for requesting and reporting on tests. It appears to have been common practice for those who could not do so to log on using a permanent member of staff’s pin number or access code, with or without their permission. The blood tests had been requested on nurse C’s ‘review’ account who denied doing so. c) If none of the witnesses who gave evidence requested the D-Dimer test it meant that another person did and could do so without any entry or note made in the A&E records. ”

    Source location

    Mark Richard HINTON · 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

    Information-security policy, login lockouts and no generic PINs were relied on to control staff access to hospital systems.

    Verbatim wording from the response

    “b. The evidence indicated that agency nurses and locum doctors did not have access to the hospital systems, in particular the “review” system for requesting and reporting on tests. It appears to have been common practice for those who could not do so to log on using a permanent member of staff’s pin number or access code, with or without their permission. The blood tests had been requested on nurse C’s ‘review’ account who denied doing so.”

    Source location

    2019-0142-Response-by-The-Shrewsbury-and-Telford-Hospital-NHS-Trust
    Page 2 · response
    Published 14 June 2019

    Open published response

  4. Inner North London

    AI-generated summary

    Margaret Emily TUCK · 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 Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

    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

    Unavailability of Datix reporting access for agency nurses

    Wider context from the report

    “6. I heard at inquest that agency nurses are unable to input into the trust reporting system (Datix). Bearing in mind that at times 50% of the ward staff are agency nurses, the matron who gave evidence suggested that agency nurses could be given a card similar to that given to locum doctors, so that they would not have to trouble their colleagues to help them make such reports. She was unsure whether this idea was going to be taken forward. ”

    Source location

    Margaret Emily TUCK · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Enable agency nurses to submit Datix reports by permitting use of the senior nurse’s email address in the reporting system.

    Verbatim wording from the response

    “6. As with all staff (medical, nursing and allied healthcare professionals), no-one needs a card of any description to log on and write a Datix. All our computers have generic log-ins that are given to all staff that need to access the computers and once logged in they can use the intranet to access the Datix system. The senior nurse on duty has been re-instructed to allow agency nurses to use their email address in the reporting system.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    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

    Agency nurses can access and submit Datix reports using generic computer log-ins and the senior nurse’s email address.

    Verbatim wording from the response

    “6. As with all staff (medical, nursing and allied healthcare professionals), no-one needs a card of any description to log on and write a Datix. All our computers have generic log-ins that are given to all staff that need to access the computers and once logged in they can use the intranet to access the Datix system. The senior nurse on duty has been re-instructed to allow agency nurses to use their email address in the reporting system.”

    Source location

    2016-0273-Response-by-Barths-Health-NHS-Trust
    Page 3 · response
    Published 26 July 2016

    Open published response

  5. Norfolk

    AI-generated summary

    Graeme Alexander Kidd · 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

    Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

    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 locum doctor access to electronic care records and related systems

    Wider context from the report

    “(1) Locum Doctors do not have access to electronic CareNotes and other electronic records and systems relating to Patients ”

    Source location

    Graeme Alexander Kidd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

Back to top

Data last updated 7 September 2026