Recurring concern

Unsafe reliance on agency staff for clinical staffing

First to latest report 6 Mar 2014 — 8 Feb 2026

Reports that mention this concern
22
Times this concern has been raised
32
Stated actions linked to this concern
62

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.

What is 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 and published responses 22 reports

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

  1. Plymouth, Torbay & South Devon

    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

  2. West Sussex

    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

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

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Data last updated 7 September 2026