Recurring concern

Unsafe reliance on agency staff for clinical staffing

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First reported 6 Mar 2014•Latest report 8 Feb 2026

Definition

What this concern includes

Includes material deficiencies in the use, deployment, competence assurance, induction, supervision or continuity of agency clinical staff where the report directly connects them to reliance on agency staffing as the shared unsafe condition.

Not included

Excludes permanent-staff shortages or general workforce problems not materially involving agency staffing.
Excludes isolated individual performance failures unless the report links them to agency staffing or the resulting reliance on agency workers.
Excludes unrelated reliance on external providers, untrained people, patients, families, questionnaires or other non-staffing controls.

Reports: 22
Individual concerns: 32
Date range: 2014–2026
Stated actions: 62

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 Care5

NHS England2

Barchester Healthcare Limited1

Care Quality Commission1

Cygnet Behavioural Health Limited1

Darnall Grange Nursing Home1

Essex Partnership University NHS Foundation Trust1

Frimley Health NHS Foundation Trust1

Frimley Park Hospital1

Hc-One Limited1

Home Office1

Leeds Teaching Hospitals NHS Trust1

Malhotra Family Holdings Limited1

Medway Maritime Hospital1

National Police Chiefs’ Council1

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.

17 Apr2014
Plymouth, Torbay & South Devon
Concerns raised1
1. Failure to appropriately deploy agency nurses in demanding Medical Admissions Unit positions
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Karen Lesley Peters · 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

Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

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 appropriately deploy agency nurses in demanding Medical Admissions Unit positions
Wider context from the report
“2. Deployment of Agency Staff. On the night of 28 March 2013, Nurse A from Plan B Nursing Agency had been asked to provide cover. She started her Night Shift working in the back area of A & E. A Sister in that department was then contacted by the Site Co-ordinator and, as a consequence, Nurse A was then moved to cover a Bay in MAU. Subsequently, another nurse within MAU became ill and had to go home. Nurse A was then additionally asked to look after that further Bay. At 23:15 hours Karen was then moved into one of the Bays for which Nurse A was responsible. My concern is whether it is appropriate to put Agency Nurses in such demanding positions ahead of nurses already employed by RCHT. I would welcome your thoughts on this and whether any changes to practice have or will be implemented as a consequence. ”
Source location
Karen Lesley Peters · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Mar2014
West Sussex
Concerns raised1
1. Failure to check agency staff prior work before deployment
This report raised 12 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
  Revise nursing-agency contract terms to prohibit supplying staff who have just worked a 12-hour shift elsewhere.
  Stated by Partnerships in Care Group LimitedStated completed
Respondent positions 1
1. Position
  No agency workers were on duty, and no concern existed that staff had worked elsewhere before reporting that day.
  Stated by Partnerships in Care Group LimitedDisputes the concern
AI-generated summary

Natasha Raghoo · 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

Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover 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
Failure to check agency staff prior work before deployment
Wider context from the report
“7. Unclear as to whether checking to ensure that when using agency staff they have not already worked a shift elsewhere that day. ”
Source location
Natasha Raghoo · 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 nursing-agency contract terms to prohibit supplying staff who have just worked a 12-hour shift elsewhere.

Verbatim wording from the response
“Lessons Learned and changes made”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 5 · response
Published 6 March 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
No agency workers were on duty, and no concern existed that staff had worked elsewhere before reporting that day.

Verbatim wording from the response
“Again, I apologise but I am unclear as to the premise underlying this concern. There were no agency workers on shift at the time of Miss Raghoo’s death and no concerns were raised about staff on shift having worked anywhere else prior to reporting for work at the Dene that day.”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 5 · response
Published 6 March 2014
Open published response

Data last updated 7 September 2026

Unsafe reliance on agency staff for clinical staffing

What this concern includes

Not included

Reports over time

Most frequent recipients

Concerns and responses across reports

Concerns raised1

Failure to appropriately deploy agency nurses in demanding Medical Admissions Unit positions

Karen Lesley Peters · Prevention of Future Deaths report

Report summary

How this individual concern was interpreted

PFD Monitor interpretation

Wider context from the report

Source location

Concerns raised1

Failure to check agency staff prior work before deployment

Actions described in response 1

Respondent positions 1

Natasha Raghoo · Prevention of Future Deaths report

Report summary

How this individual concern was interpreted

PFD Monitor interpretation

Wider context from the report

Source location

How this respondent action was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

How this respondent position was interpreted

PFD Monitor interpretation

Verbatim wording from the response

Source location

Analytics settings

How can we help?

Message sent

Request a correction

Request sent

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to appropriately deploy agency nurses in demanding Medical Admissions Unit positions

Concerns raised1

Failure to check agency staff prior work 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.1

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

Actions described in response 1

Respondent positions 1