Recurring concern

Unreliable named-nurse allocation and identification

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First reported 14 Jul 2014•Latest report 29 Feb 2024

Definition

What this concern includes

Includes failures in the named-nurse system for allocating, identifying, communicating and recording the nurse responsible for each patient, including delayed or absent allocation, allocation without the nurse's or patient's knowledge, and missing records of the appointment.

Not included

  • Excludes failures in the named nurse's subsequent care, engagement, risk assessment or one-to-one sessions when named-nurse allocation and identification were reliable.
  • Excludes generic nursing staffing, handover, communication or record-keeping deficiencies unless they directly impair the named-nurse allocation and identification system.
  • Excludes allocation of named consultants, care coordinators or other roles unless the assertion explicitly concerns the named-nurse system.
  • Excludes unrelated allocation of resources, tasks, care types or staff to positions.
Reports
4

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
4

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.

Devon Partnership NHS Trust2
Department of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
NHS England1
Nottinghamshire Healthcare NHS Foundation Trust1
Ofcom1

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. Nottinghamshire

    AI-generated summary

    Daniel Mark Edward TUCKER · 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

    Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.

    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 allocation of named nurses to patients

    Wider context from the report

    “2. Inadequate system of allocating a named nurse to patients and recording the same I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises. The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed. ”

    Source location

    Daniel Mark Edward TUCKER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 record the named nurse appointed to each patient

    Wider context from the report

    “2. Inadequate system of allocating a named nurse to patients and recording the same I am concerned that, notwithstanding the existence of a clear, appropriate policy requiring the same, the current system of allocating a named nurse and ensuring patients receive regular and effective 1:1 sessions with them are inadequate. I am also concerned that no record is kept of the named nurse appointed to each patient, thus (as in this case) hindering any investigation where issue around the role and actions of that person arises. The General Manager of Adult Mental Health at the Trust helpfully and frankly acknowledged that the evidence heard at inquest raised questions about the adequacy of the existing system, of which he was not previously aware of. It remains unclear whether Daniel was appointed a Named Nurse who failed to perform that role effectively, or whether there was a failure to appoint such a nurse at all. The General Manager’s view was that under the existing system, it is possible that a named nurse was appointed without their knowledge. While the Ward Manager gave evidence that she would have no confidence Daniel would have known who his named nurse was, even if one was appointed. The inquest heard evidence that named nurse sessions with Daniel during previous admissions had been important opportunities for engagement with staff and had elicited a substantial amount of information pertinent to his risk and treatment. The General Manager assured me that he has already requested an urgent review of the system, but he was unable to provide any further information upon conclusion of the inquest as to what further action, if any, is proposed. ”

    Source location

    Daniel Mark Edward TUCKER · 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

    Review and revise named-nurse allocation in adult mental health acute wards, including allocation on admission where possible.

    Verbatim wording from the response

    “It was recognised within the inquest that an urgent review was needed for the system of named nursing within AMH inpatient acute wards. This work is being led by the Head of Nursing at Highbury Hospital. The expectation would be for named nurses to be allocated on admission and wherever possible this should be the admitting nurse due to continuity of care. Where this is not possible for example where a staff member will be taking some annual leave, an alternative nurse anticipated to be working within the 72 hours will be allocated. This is current work in progress and in the engagement phase with the ward teams.”

    Source location

    Response from Nottinghamshire Healthcare
    Page 3 · response
    Published 6 March 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

    Record each patient’s named nurse in the care plan and audit compliance.

    Verbatim wording from the response

    “To ensure that all patients know of their named nurses and that there is a clear record of this an interim measure has been agreed for the named nurse to be cleared detailed within the care plan. For the patients experience this will mean that upon receipt of their care plan they will have this detail to hand and will be confident of who their named nurse is. This will also provide a record should the identification of the named nurse be required for”

    Source location

    Response from Nottinghamshire Healthcare
    Page 3 · response
    Published 6 March 2024

    Open published response
  2. Essex

    AI-generated summary

    David John Pooley · 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 John Pooley, aged 66, was admitted to hospital after attempting to hang himself and was later found hanging in a ward toilet; his death was confirmed on 20 May 2015. Concerns included the absence of a named nurse until the day before his death and the resulting failure to carry out appropriate risk assessments, care planning and reviews.

    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 allocate a named nurse

    Wider context from the report

    “1. Contrary to the trust’s policy, there was no named nurse allocated until the day before Mr Pooley’s death. The role of the named nurse had not therefore been carried out – this entails the devising of a risk assessment, care plans, one to ones, contact with the patient’s family etc. 2. The appropriate assessments and reviews were therefore not carried out. ”

    Source location

    David John Pooley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  3. Exeter & Great Devon

    AI-generated summary

    Polly Elisabeth Jane CARPENTER · 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

    Polly Elisabeth Jane Carpenter, who had a history of psychotic depression and repeated suicide attempts, left an inpatient psychiatric unit on 5 May 2011 and deliberately sat on a railway track, where she was struck by a train and died. The concerns included weaknesses in recording risk assessments, observations and nurse allocation, limited staff awareness of current risk, and inadequate security of unit windows, which contributed to her absconding.

    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

    Nebulous execution of the named nurse system

    Wider context from the report

    “(1) The Evidence of Named Nurse system which was in operation at the time of Polly’s death indicated its execution to be somewhat nebulous. I am encouraged by ████████ Evidence that the Trust has taken up the challenge and instituted new steps with 1:1 time and the placement of a ward board with names of nurses allocated to each patient so improving patient's access to them. ”

    Source location

    Polly Elisabeth Jane CARPENTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Exeter & Great Devon

    AI-generated summary

    Elaine JOBE · 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

    Elaine JOBE, an informal voluntary psychiatric patient aged 53, was found hanging in a bathroom at Ocean View on 2 February 2011 after being placed on general hourly observation. Resuscitation and transfer to hospital did not avert her death. Concerns included inadequate records of risk assessments and observations, staff training, and communication of patient status and monitoring responsibilities between shifts.

    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 identify a named nurse responsible for each patient on every shift

    Wider context from the report

    “(3)Communication of patient status to incoming staff Communication of patient status with other members of staff and identification of a named nurse with responsibility for each patient on every shift needs to be reviewed so all staff are clear as to which patients they must monitor. ”

    Source location

    Elaine JOBE · 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

    Audit shift planners randomly to verify completion of all required areas.

    Verbatim wording from the response

    “7/ Random audit of the shift planners to be carried out to ensure completion of all areas.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 6 · response
    Published 14 July 2014

    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

    Use ward allocation boards, shift planners, staff identification boards and minimum handover standards to communicate patient allocations and status to incoming staff.

    Verbatim wording from the response

    “Since the death of Elaine the ward has an allocation board that is completed for every 24-hour period, showing the staff on duty and which patients they are allocated to. The board is in a prominent position on the ward so that staff and patients can see it. Next to this board is a staff photo board to help patients recognise staff members if they are new to the ward.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 4 · response
    Published 14 July 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

    Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.

    Verbatim wording from the response

    “The Trust has policies, standards and guidance in place for the areas of concern noted in the report. It is not seen as required to introduce new standards, but to ensure the embeddedness of those currently in place. The Trust has several assurance measures in place, but further actions as described below will be put in place to provide additional assurance.”

    Source location

    2014-0350-Response-by-Devon-Partnership-NHS-Trust
    Page 5 · response
    Published 14 July 2014

    Open published response
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Data last updated 7 September 2026