Recurring concern

Unreliable staffing cover during care-staff breaks

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First reported 28 Mar 2018•Latest report 14 Jan 2020

Definition

What this concern includes

Includes failures to schedule, stagger, cover or provide relief for care staff breaks when those failures can leave a patient without required one-to-one supervision or leave a ward without adequate care and observation cover.

Not included

  • Excludes general staffing shortages, workload or fatigue concerns where staff-break coverage is not the shared unsafe condition.
  • Excludes failures in the quality of one-to-one care or general patient supervision when staff-break arrangements are not deficient.
  • Excludes staff-break issues in non-care settings, such as delivery driving or ordinary office work, unless they directly concern maintaining safety-critical care coverage.
  • Excludes isolated missed breaks where no continuing deficiency in scheduling, relief or coverage arrangements is asserted.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2020

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Bristol NHS Foundation Trust1
Nursing and Midwifery Council1
St George'S University Hospitals NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. London Inner (West)

    AI-generated summary

    John David Long · 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 David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one care.

    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 safe break and relief arrangements during 1:1 care

    Wider context from the report

    “2. A review is required into the use of 1:1 (one to one) care in hospital wards and in particular a review into the definition of what 1:1 (one to one) care actually means. In addition a review on how it is administered on the ward and what rules there are for those nurses and Carers to comply with when carrying out such care for a patient. Furthermore there needs to be very clear rules about how Carer or nurse carrying out such care ensures they have sufficient breaks from providing such care and how they are relieved from their duties in such circumstances but ensuring the Patient is not left alone at any time. ”

    Source location

    John David Long · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Avon

    AI-generated summary

    John Frederick Wherlock · 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 Frederick Wherlock was an inpatient at Bristol Royal Infirmary who was elderly, confused and at high risk of falls. He was left unsupervised while ward staffing was reduced because two staff were taking breaks at the same time, fell and fractured his other hip, and subsequently died. The principal concerns were inadequate cover during simultaneous staff breaks and the continuation of that practice despite it having been criticised in a serious untoward incident report.

    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 stagger staff breaks to maintain adequate ward cover

    Wider context from the report

    “(1) I was told in evidence that at the time of the accident the ward was being covered by two nurses and two nursing assistants (ie, by 4 staff), but that two of those staff had taken their 1-hour break at the same time; effectively leaving the ward with very little cover. The fall had then occurred when a nursing assistant left the deceased’s bay to help another member of staff to change a bed (leaving him entirely unsupervised). (2) While I would be concerned in any event that staff had taken their breaks at the same time – given the effect that that would inevitably have on the remaining nurses’ ability to cope with the patients on the ward – I was even more concerned when the nursing assistant who gave live evidence at the inquest told me that this was a practice which was still taking place; despite it having been highlighted and criticised in the serious untoward incident report; ”

    Source location

    John Frederick Wherlock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026