16 Jun 2025 Mrs Norma Faye Campbell · Prevention of Future Deaths report East London
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Concerns raised 1
Inadequate staffing in A&E View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
Barts Health NHS Trust
Increase Emergency Department medical staffing to the approved establishment, completing recruitment of resident doctors and consultant grades.
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Barts Health NHS Trust
Recruit to the approved increase of 10.5 whole-time-equivalent Emergency Department nursing posts.
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Barts Health NHS Trust
Open and operate a 17-bed temporary escalation space with dedicated nursing and medical staff to relieve Emergency Department capacity pressures.
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AI-generated summary
Mrs Norma Faye Campbell · 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
Mrs Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate staffing in A&E
Wider context from the report “1. The inquest heard that the A&E department at Whipps Cross Hospital often has inadequate staffing and medical facilities to address the patient numbers and acuity. The inquest heard that overcrowding in A&E is a national concern.
” Source location Mrs Norma Faye Campbell · Prevention of Future Deaths report
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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 Increase Emergency Department medical staffing to the approved establishment, completing recruitment of resident doctors and consultant grades.
Verbatim wording from the response “In May 2024, the Hospital Executive Board at Whipps Cross Hospital approved the increase in whole time equivalent (WTE) medical staff from 43 WTE to 63 WTE. This was an increase in 1.1 WTE consultants, 10 WTE Tier A (registrar) grade residents and 5 additional Paediatric Emergency residents (4 at registrar grade and 1 at senior house officer grade). In addition, locum shifts equivalent to 5 WTE were also approved as part of the staffing to ensure that the department was appropriately always staffed. Recruitment has been ongoing since June 2024 and for August 2025, the agreed establishment will be fully recruited for resident doctors with successful interviews for the consultant grades on 17th July 2025. This brought Whipps Cross into line with the other Emergency Departments within Barts Health for medical staffing.” Source location Response from Barts Health NHS Foundation Trust
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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 Recruit to the approved increase of 10.5 whole-time-equivalent Emergency Department nursing posts.
Verbatim wording from the response “For nursing staff, the Hospital Executive Board has approved an increase in 10.5 WTE nursing staff in line with the Safer Nursing Care Tool review of staffing and is currently in the process of recruiting to these posts.” Source location Response from Barts Health NHS Foundation Trust
Open published response
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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 Open and operate a 17-bed temporary escalation space with dedicated nursing and medical staff to relieve Emergency Department capacity pressures.
Verbatim wording from the response “Where we do have days that there is overcrowding within the Emergency Department, additional nurses are redeployed to provide “fundamentals of care” and care for the patients waiting to be admitted to the hospital. In winter 2024/2025 an additional 17 bedded “temporary escalation space” was opened with dedicated nursing and medical staff next to the Emergency Department to care for patients who required admission to hospital and had already commenced treatment to free up space within the Emergency Department for patients who were requiring assessment.” Source location Response from Barts Health NHS Foundation Trust
Open published response
26 May 2025 Sarah Kathleen Hill · Prevention of Future Deaths report Cumbria
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Concerns raised 1
Insufficient ward nursing capacity for safe patient allocation View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sarah Kathleen Hill · 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
Sarah Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient ward nursing capacity for safe patient allocation
Wider context from the report “(5) I was advised that the ward was understaffed and under pressure . I was told that despite this being appropriately escalated nurses were caring for 10 patients when the expected allocation would be 6 patients for each nurse on duty .No further help was provided to the ward following escalation . The evidence presented to me was that this was not an unusual situation on the ward .
” Source location Sarah Kathleen Hill · Prevention of Future Deaths report
Open source report
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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 and implement the Safe Staffing Escalation SOP, including 30-minute action triggers and nurse-to-patient ratio review.
Verbatim wording from the response “Staffing Escalation SOP Review: The Trust’s Safe Staffing Escalation SOP will be revised and implemented to ensure that unmet staffing thresholds trigger action within 30 minutes, including redeployment. This will include a review of nurse-to-patient ratios.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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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 Develop and pilot a two-zone ward layout with two registered nurses to improve visibility and responsiveness.
Verbatim wording from the response “Ward Layout Improvements: A proposal to split the corridor where the single rooms are, into two zones with two registered nurses is being developed and will be piloted to improve nurse-patient ratios in this part of the ward.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
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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 Recruit to the approved AMU establishment of eight qualified day nurses and seven night nurses.
Verbatim wording from the response “Concern 5: Staffing Levels and Escalation Response
Response:
The AMU have experienced nurse staffing difficulties with temporary escalation beds being open indefinitely. This has significantly impacted the ability to staff the ward in line with the recommended safe nurse staffing ratio of 1:6. This was acknowledged by the Trust in 2025 and an increased funded establishment was awarded in April 2025. The AMU is now ensuring that staffing levels are maintained at a minimum of six qualified nurses 24 hours per day to maintain a maximum nurse-to-patient ratio of 1:7.8 (nurse in charge plus 5 nurses for 39 patients). Furthermore, a new safe staffing establishment was approved in April 2025 for the ward, increasing staffing levels to eight qualified nurses during the day and seven at night.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
1 May 2025 Peter Michael ANZANI · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Inadequate workforce staffing capacity View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
NHS England
Complete an internal review of the Coroner’s findings and formal workforce funding requests for the SCI service.
View source
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AI-generated summary
Peter Michael ANZANI · 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
Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.
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× 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 workforce staffing capacity
Wider context from the report “1. I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (”The Trust”) have been experiencing difficulties with patient waiting lists - due to both an increase in the quantity of patients being treated and staffing shortages - which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months.
2. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a "no growth policy".
3. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming).
4. It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or review, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment.
5. In light of HM Government's decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.
” Source location Peter Michael ANZANI · Prevention of Future Deaths report
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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 Complete an internal review of the Coroner’s findings and formal workforce funding requests for the SCI service.
Verbatim wording from the response “NHS England was not given Interested Party status or asked to provide any witness evidence during the inquest into Peter’s death. The Coroner’s findings have resulted in an internal NHS England review and we have not identified any specific formal workforce funding requests that have been rejected by NHS England for the SCI service at RJAH with regard to outpatient services.” Source location Response from NHS England
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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 formal workforce funding requests for RJAH’s outpatient spinal injury service were identified as having been rejected by NHS England.
Verbatim wording from the response “NHS England’s Specialised Commissioning funds RJAH’s SCI service as part of a block funded commissioning system to cover the complete costs for the service, including inpatient and outpatient activity with inflationary finance being applied to all NHS England contracts annually since 2020. As a Foundation Trust, RJAH take organisational decisions on individual service spends, including workforce, to deliver services as identified in the national service specification. In June 2024, a Trust internal workforce review was shared for information with NHS England and we understand this is being updated at this current time. No formal requests for funding have been received through the contract review meeting process between RJAH and NHS England, to support the findings of the RJAH internal review.” Source location Response from NHS England
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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 RJAH, as a Foundation Trust, makes organisational decisions about workforce spending within its block-funded spinal injury service.
Verbatim wording from the response “NHS England’s Specialised Commissioning funds RJAH’s SCI service as part of a block funded commissioning system to cover the complete costs for the service, including inpatient and outpatient activity with inflationary finance being applied to all NHS England contracts annually since 2020. As a Foundation Trust, RJAH take organisational decisions on individual service spends, including workforce, to deliver services as identified in the national service specification. In June 2024, a Trust internal workforce review was shared for information with NHS England and we understand this is being updated at this current time. No formal requests for funding have been received through the contract review meeting process between RJAH and NHS England, to support the findings of the RJAH internal review.” Source location Response from NHS England
Open published response
24 Apr 2025 Jacqueline Anne Potter · Prevention of Future Deaths report Somerset
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Concerns raised 1
Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Jacqueline Anne Potter · 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
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient availability of specialist menopausal practitioners in primary and Trust-wide care
Wider context from the report “(ii) I was told that the Trust has just one ‘menopause specialist’ (a GP) who covers the entire Trust operations . Not all GP surgeries have a menopause specialist practitioner (or access to one) despite a GP usually being the first port of call for women in the community when seeking primary care. Those GP Surgeries who do have a practitioner who acts as a ‘specialist’ is often a GP with a personal interest who has taken the initiative to go on courses and broaden their learning and understanding, rather than any mandatory requirement for a Surgery [or group with multiple surgeries] to have an available community ‘front-line’ specialist .
I was told that the Trust does not have an “expert” in this field and it would be difficult to have one as menopause isn’t a disease or an illness. Whilst I do not dispute that is it not a disease, menopause is a condition; it does have symptoms and it does have recognised presentations, yet there appears to be a failure to recognise this condition as having equal importance to other ailments or diagnoses.
” Source location Jacqueline Anne Potter · Prevention of Future Deaths report
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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 Work with regions and Integrated Care Boards to improve nationwide access to good menopause care.
Verbatim wording from the response “There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.” Source location Response from NHS England
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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 NHS England and the Royal Colleges are better placed to address the lack of NHS menopause specialists and services.
Verbatim wording from the response “4. Lack of menopause specialists or menopause services in the NHS” Source location Response from NICE
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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 NHS England and the Royal Colleges are better placed to address the lack of specialist menopausal care and GP upskilling.
Verbatim wording from the response “5. There has not been a roll-out of specialist menopausal care and upskilling of GPs, as was promised in a previous PFD.” Source location Response from NICE
Open published response
19 Feb 2025 Margaret Kathleen Rodgers · Prevention of Future Deaths report Surrey
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Concerns raised 1
Insufficient ward nursing staffing levels to meet the demand of acutely ill patients with high dependency needs View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Surrey and Sussex Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Surrey and Sussex Healthcare NHS Trust
Carry out the biannual Safer Nursing Care Tool review of ward establishments and assess necessary staffing increases.
View source
Surrey and Sussex Healthcare NHS Trust
Incorporate additional shifts into the Nuffield Ward roster template and use temporary staffing to address staffing requirements.
View source
Surrey and Sussex Healthcare NHS Trust
Maintain an additional nursing assistant on the Nuffield Ward night rota to support patient safety.
View source
Surrey and Sussex Healthcare NHS Trust
Assess ward acuity daily and escalate concerns to secure additional staff or redeploy staff between wards when necessary.
View source
Surrey and Sussex Healthcare NHS Trust
Hold twice-daily safer-staffing huddles to review staffing gaps, mitigation, redeployment and temporary staffing needs, escalating unresolved issues to the Chief Nurse.
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AI-generated summary
Margaret Kathleen Rodgers · 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 Kathleen Rodgers fell at home on 3 December 2023, sustained rib and spinal fractures, and was admitted to hospital. During her admission she developed hospital-acquired pneumonia, a sacral pressure ulcer requiring two surgical procedures, and a urinary tract infection; she died from congestive cardiac failure on 12 January 2024. The coroner was concerned that unresolved recommendations about pressure-ulcer risk assessments and ward staffing were placing patients at risk of early death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient ward nursing staffing levels to meet the demand of acutely ill patients with high dependency needs
Wider context from the report “b. The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs . The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget .
” Source location Margaret Kathleen Rodgers · Prevention of Future Deaths report
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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 Carry out the biannual Safer Nursing Care Tool review of ward establishments and assess necessary staffing increases.
Verbatim wording from the response “The second concern was as follows: 'The court also heard that in December 2023 to January 2024, the period of Mrs Rodgers admission, the hospital was experiencing a high level of operational pressures and that on occasions the ward itself had insufficient nursing staff levels to meet the demand of acutely ill patients with high dependency needs. The Trust is undertaking a review of the staffing template for the ward, but that work is not complete and not yet incorporated into the budget.'” Source location Response from Surrey Sussex NHS Trust
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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 Incorporate additional shifts into the Nuffield Ward roster template and use temporary staffing to address staffing requirements.
Verbatim wording from the response “staffing increases have not yet been reflected in the ward budgets, Nuffield Ward has addressed this by incorporating additional shifts into the roster template and utilising temporary staffing.” Source location Response from Surrey Sussex NHS Trust
Open published response
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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 Maintain an additional nursing assistant on the Nuffield Ward night rota to support patient safety.
Verbatim wording from the response “2) Staffing levels on Nuffield ward are 5 qualified nurses and 3 non-qualified staff during the day, and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have an extra nursing assistant than the template allows and this was recognised through the need for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess the acuity on wards on a daily basis and will use clinical decision making to ensure that wards are safe, if there are any concerns they will escalate to senior management and additional staff will be requested for that shift if necessary. We are also able to move staff to work on different wards if acuity requires it.” Source location Response from Surrey Sussex NHS Trust
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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 Assess ward acuity daily and escalate concerns to secure additional staff or redeploy staff between wards when necessary.
Verbatim wording from the response “2) Staffing levels on Nuffield ward are 5 qualified nurses and 3 non-qualified staff during the day, and 3 qualified and 3 non-qualified at night. We have already increased the night rota to have an extra nursing assistant than the template allows and this was recognised through the need for acuity, and we allow this as a cost pressure to maintain patient safety. The matrons assess the acuity on wards on a daily basis and will use clinical decision making to ensure that wards are safe, if there are any concerns they will escalate to senior management and additional staff will be requested for that shift if necessary. We are also able to move staff to work on different wards if acuity requires it.” Source location Response from Surrey Sussex NHS Trust
Open published response
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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 Hold twice-daily safer-staffing huddles to review staffing gaps, mitigation, redeployment and temporary staffing needs, escalating unresolved issues to the Chief Nurse.
Verbatim wording from the response “The Trust holds twice daily safer staffing huddles, attended by the Head of Nursing or a matron representative. During these meetings, each division reports staffing levels, mitigation actions taken, and any remaining gaps. The staffing situation is reviewed using the Safe Care Live system to identify potential cross-divisional moves or the need for temporary staffing. If these options are insufficient, corporate nursing teams are deployed to provide clinical support. The meeting also reviews staffing for the next day and on Fridays the weekend staffing is also considered. If staffing issues cannot be resolved, they are escalated to the Chief Nurse for further action.” Source location Response from Surrey Sussex NHS Trust
Open published response
13 Dec 2024 LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report Essex
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Concerns raised 1
Insufficient experienced doctor skill mix on the Labour Ward View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
LAURA-JANE KIRSTEN NICOLE SEAMAN · 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
Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient experienced doctor skill mix on the Labour Ward
Wider context from the report “(9) Staff skill mix for doctors on the Labour Ward for the night of 20/21 December was staffed with a junior obstetric registrar with a newly qualified colleague in his first week and a junior anaesthetist, all with limited experience of working on the Labour Ward .
” Source location LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report
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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 Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
Verbatim wording from the response “We now have a new rota system in place where the required staffing establishment must include a junior registrar paired with a senior registrar. The junior then has a point of escalation to ensure that any MEWS score of four or above is escalated to the senior registrar and onto the Consultant.” Source location Response from Mid & South Essex NHS Trust
Open published response
23 Apr 2024 Ronald Henry SPENCER · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure to maintain sufficient staffing for timely patient medical care View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Birmingham and Solihull Integrated Care Board NHS England University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 12
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Deploy senior fellows to cover consultant rota gaps with consultant oversight.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Appoint three emergency-surgery locum consultants and an academic colorectal consultant to increase rota resilience.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Complete an independent review of elective and emergency upper-GI care and service configuration.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Consider all recommendations from the independent upper-GI service review.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Introduce the NHS Long Term Workforce Plan and Framework 15.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Complete a high-level diagnostic of current and future workforce demand and supply.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Operate the 4R’s Workforce Delivery Framework with allocated resources supporting implementation over two years.
View source
NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation Trust
Deliver workforce programmes addressing diagnostic risks, including sustainable staffing, retention, training and workforce-plan foundations.
View source
Department of Health and Social Care
Provide £200 million in additional funding to expand ambulance service capacity and improve response times.
View source
Department of Health and Social Care
Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
View source
NHS England
Deliver the Long-Term Workforce Plan, expanding domestic education, training and recruitment while improving staff culture, leadership and wellbeing.
View source
NHS England
Plan for and provide system support ahead of winter pressures through operational, surge, cross-system and workforce preparedness measures.
View source See 9 more actions
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Ronald Henry SPENCER · 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
Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to maintain sufficient staffing for timely patient medical care
Wider context from the report “1. I heard evidence that there were significant staffing issues during the Ronald's period of in-patient care that caused delays to his treatment . Whilst there was no direct evidence at the inquest that these delays caused or contributed to death, any delays in patients receiving medical care due to a lack of staff clearly presents a risk of future deaths occurring.
2. It is recognised that the reasons for delay can be multifactorial, with so called "winter pressures" causing an influx of ill patients and heightened staff absences. "Winter pressures" are now a regular annual event and put significant strain on the NHS. There can be no doubt that patients have died, and will continue to die, from avoidable deaths due to delays caused by these staffing inadequacies .
” Source location Ronald Henry SPENCER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy senior fellows to cover consultant rota gaps with consultant oversight.
Verbatim wording from the response “In response to matters of concern in relation to staff shortages at UHB, it is noted that the Inquest found no evidence to suggest that the standard of clinical care provided to Mr Spencer contributed to his death. However, we recognise that at the time of his death there was an unprecedented strain on the general surgical consultant workforce at UHB as a result of anticipated sickness absence of three surgeons. Steps had been taken to mitigate the impact of the exceptional workforce pressures which included arranging for two senior fellows, both of whom had completed registrar training, to "act up" and cover any identified gaps on the consultant rota. Both fellows were considered to be sufficiently skilled and experienced and consultant support was also put in place so that there was oversight of their temporary roles.” Source location Response from Birmingham and Solihull
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Appoint three emergency-surgery locum consultants and an academic colorectal consultant to increase rota resilience.
Verbatim wording from the response “Since the time of Mr Spencer’s admission in December 2023, three locum consultants in emergency surgery have been appointed as well as an academic colorectal consultant. As a result, there is increased resilience in the emergency surgery rota than was the case when Mr Spencer was admitted.” Source location Response from Birmingham and Solihull
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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 Complete an independent review of elective and emergency upper-GI care and service configuration.
Verbatim wording from the response “It has also been recognised that the current staffing model in place, which includes four dedicated esophago-gastric consultants running the specialist upper GI on-call service for the region, may represent an additional vulnerability within the service, particularly at times of increased demand. The UHB upper GI service has recently undergone an independent invited review which has been conducted by the East Midlands Clinical Senate. The review encompassed all aspects of elective and emergency upper GI care at the QEΗ. The final report is awaited, but it is anticipated that recommendations will likely include reviewing the current esophago-gastric service configuration and increasing the number of consultants” Source location Response from Birmingham and Solihull
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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 Consider all recommendations from the independent upper-GI service review.
Verbatim wording from the response “It has also been recognised that the current staffing model in place, which includes four dedicated esophago-gastric consultants running the specialist upper GI on-call service for the region, may represent an additional vulnerability within the service, particularly at times of increased demand. The UHB upper GI service has recently undergone an independent invited review which has been conducted by the East Midlands Clinical Senate. The review encompassed all aspects of elective and emergency upper GI care at the QEΗ. The final report is awaited, but it is anticipated that recommendations will likely include reviewing the current esophago-gastric service configuration and increasing the number of consultants” Source location Response from Birmingham and Solihull
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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 Introduce the NHS Long Term Workforce Plan and Framework 15.
Verbatim wording from the response “BSol ICB recognises the need for a workforce that is sufficient in numbers and skills to care for patients throughout the calendar year and works with all system partners to ensure this. We are also committed to the introduction of the NHS Long Term Workforce Plan and Framework 15.” Source location Response from Birmingham and Solihull
Open published response
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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 Complete a high-level diagnostic of current and future workforce demand and supply.
Verbatim wording from the response “In June 2023, BSol ICB carried out a high-level diagnostic of the current and future workforce looking at both demand and supply drawing upon BSol strategy and operational documents. It identified that workforce is an immediate and urgent priority for the ICB and supports the system in responding to the NHS Long Term Workforce Plan and Framework 15.” Source location Response from Birmingham and Solihull
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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 Operate the 4R’s Workforce Delivery Framework with allocated resources supporting implementation over two years.
Verbatim wording from the response “The 4R’s Workforce Delivery Framework is now operational and significant resource has been allocated to support implementation over the next two years. This investment will be used to sustain the delivery of existing programmes where they have been identified as supporting the 4R’s as well as a range of additional priorities identified as part of the Workforce Diagnostic.” Source location Response from Birmingham and Solihull
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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 Deliver workforce programmes addressing diagnostic risks, including sustainable staffing, retention, training and workforce-plan foundations.
Verbatim wording from the response “• Deliver key programmes of work that have been identified as critical to address the risks and challenges identified within the workforce diagnostics which will enable:” Source location Response from Birmingham and Solihull
Open published response
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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 Provide £200 million in additional funding to expand ambulance service capacity and improve response times.
Verbatim wording from the response “To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
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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 Provide £1 billion in dedicated funding to increase staffed core hospital beds by 5,000 compared with 2022/23 plans.
Verbatim wording from the response “To support ambulance services, ambulance trusts received £200 million of additional funding in 2023/24 to expand capacity and improve response times. In addition, to improve patient flow and bed capacity within hospitals £1 billion of dedicated funding was provided to increase staffed core hospital beds by 5,000 compared to 2022/23 plans.” Source location Response from Department of Health and Social Care
Open published response
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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 Deliver the Long-Term Workforce Plan, expanding domestic education, training and recruitment while improving staff culture, leadership and wellbeing.
Verbatim wording from the response “NHS England is working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years. These actions will aim to close anticipated staffing shortfalls in the NHS in the long term.” Source location Response from NHS England
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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 Plan for and provide system support ahead of winter pressures through operational, surge, cross-system and workforce preparedness measures.
Verbatim wording from the response “NHS England continues to plan for and provide support to systems ahead of winter pressures. Further information and links to historic plans and letters to our systems can be found on our winter resilience website pages. For the most recent winter period (2023/24), we sent out a letter to our Integrated Care Boards and Trusts, setting out our national approach to winter planning and our four areas of focus:” Source location Response from NHS England
Open published response
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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 inquest found no evidence that the standard of clinical care contributed to Mr Spencer’s death.
Verbatim wording from the response “In response to matters of concern in relation to staff shortages at UHB, it is noted that the Inquest found no evidence to suggest that the standard of clinical care provided to Mr Spencer contributed to his death. However, we recognise that at the time of his death there was an unprecedented strain on the general surgical consultant workforce at UHB as a result of anticipated sickness absence of three surgeons. Steps had been taken to mitigate the impact of the exceptional workforce pressures which included arranging for two senior fellows, both of whom had completed registrar training, to "act up" and cover any identified gaps on the consultant rota. Both fellows were considered to be sufficiently skilled and experienced and consultant support was also put in place so that there was oversight of their temporary roles.” Source location Response from Birmingham and Solihull
Open published response
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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 Trusts are responsible for ensuring safe staffing levels in the current day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from Department of Health and Social Care
Open published response
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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 Local staffing and workforce arrangements are the responsibility of NHS Birmingham and Solihull ICB and University Hospitals Birmingham NHS Foundation Trust.
Verbatim wording from the response “Trusts do have a responsibility to ensure safe staffing levels in the current day to day operation of their hospitals. This is in line with the Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
17 Apr 2024 Margaret Avril Burman · Prevention of Future Deaths report Wiltshire and Swindon
View report summary
Concerns raised 1
Insufficient staffing and resources for falls mitigation on hospital wards View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Margaret Avril Burman · 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 Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staffing and resources for falls mitigation on hospital wards
Wider context from the report “As I have previously indicated in a Regulation 28 Report submitted to you (Raymond Eggleton dated 17th November 2023 which remains unanswered by you) (Department of Health) falls in the hospital environment do not happen, however, as of the view in Avril’s case that had there been an appropriate Healthcare Assistant present then Avril’s fall and death more likely than not would have been avoided.
During the course of the Inquest, I heard evidence from the Hospital’s Falls Specialist, ████████ who indicated that whilst staffing issues have improved there remains a difficulty ensuring appropriate staffing especially when responding to the ever-changing needs on wards where they are occupied by people at risk of falls . She explained to me that in relation to 2 wards in particular, one of which included Spire Ward which is a general geriatric surgical ward and the other which is a trauma and orthopaedic ward, both of which can take approximately 30 patients, that having conducted her own analysis it is transpired that of those admitted onto both those wards that approximately 80% either had a history of falls or the reason for their admission related to a fall. Of those at risk of a fall where the enhanced care toolkit had been deployed, she told me that 70% of those at falls risk required and warranted 1 to 1 support. Generally, these wards have a nursing ratio of between 1 to 8 patients or sometimes 1 to 6 patients with appropriate Healthcare Assistant support. As you can see in relation to a ward of 30 patients, a situation starts to present itself where the majority of personnel on the ward are not providing nursing support but are providing 1 to 1 falls mitigation support, and there simply are not the resources available to provide such cover . As a consequence, where there is an identifiable falls risk, the situation arises and continues at the moment where those patients are not being appropriately safeguarded against the risk of falls on wards . Especially where patients have conditions such as Dementia and Alzheimer’s it can sometimes be the case that it only takes a relatively minor collapse to cause a significant head trauma that leads to death.
The position is further compounded by the fact that I was told the hospital is confronted with the additional problem that it can have up to 70% of those patients on these 2 wards being in a condition where they are medically stabilised and fit to be discharged but due to lack of appropriate care in the community they are remaining on the wards. The longer they remain on the wards the greater the risk of falls especially if they are medically stabilised when in such circumstances, they are more likely to be mobile.
I asked ████████ as to how she thought that improvements could be made and she indicated to me in her evidence that she was of the view that there should be national leadership and a standardised toolkit when assessing falls risks on hospital wards and that there should also be a greater degree of sharing of learning where methods of good practice have been adopted by other Trusts that could easily be adopted by Trusts where this is a challenge.
As I indicated in Mr Eggleton’s Regulation 28 Report, the problem here is multifactorial but as it remains at the moment, I am concerned that the elderly on hospital wards are at significant risk of sustaining a traumatic and fatal injury by having a fall on a ward due to the unavailability of appropriate and necessary falls mitigation measures .
The resolution of this problem is not about the amount of money or the increase in money that is injected into the National Health Service and my concern is that a more strategic approach is required. More money may well indeed be injected into the National Health Service but with inflation as it has been and with wage rises that have taken place in real terms the increase maybe small and the reality is that in real terms it may amount to a reduction in what can be purchased with that money.
The commitment to provide 5000 extra “core” beds to deal with increasing demand is only going to add to the concern unless this issue is addressed.
As I have stated in my last Regulation 28 Report dealing with this issue, the problem is multifactorial, but it is a solution in respect of which the government undoubtedly has a crucial and essential role to play.
” Source location Margaret Avril Burman · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and provide national falls-risk guidance and implementation toolkits for hospital patients at risk of falls.
Verbatim wording from the response “Your Report raises concerns over appropriate staffing falls mitigation measures on wards occupied by people at risk of falls, in particular patients with dementia or Alzheimer’s Disease, and that there should be ‘national leadership and a standardised toolkit when assessing falls risk on hospital wards’ and that there should also be a greater degree of sharing of learning.” Source location Response from NHS England
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the NHS Long Term Workforce Plan to increase, train, retain and reform the NHS workforce.
Verbatim wording from the response “Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.” Source location Response from NHS England
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing national falls guidance and implementation toolkits are considered sufficient to support appropriate falls-risk assessment and interventions.
Verbatim wording from the response “National leadership has already developed national guidance based on evidence-based practice which include falls risk assessment and toolkits to support implementation of appropriate interventions. At the time of Margaret’s admission to hospital in 2021, there was existing guidance available to support best practice around patients at risk of falls.” Source location Response from NHS England
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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 Local nurse leaders are responsible for calculating safe staffing levels, with NHS Trust boards reporting staffing levels to NHS England.
Verbatim wording from the response “Regarding staffing levels, the headcount for registered nurses and support staff has increased over the last decade,² however difficulties do remain in ensuring appropriate levels of staffing, especially to cover wards where patients are at risk of falls. Local nurse leaders are responsible for calculating safe levels of staffing using the Safer Nursing Care Tool - Sheffield Group and Boards for NHS Trusts have been required to report on their staffing levels to NHS England on a six-monthly basis since 2014.” Source location Response from NHS England
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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 Responsibility for responding to the report’s concerns rests with NHS England, so no duplicate response will be provided.
Verbatim wording from the response “I am aware that that the National Medical Director is responding to your report on behalf of NHS England and as such I do not intend to duplicate the contents of his communication with you. However, I am assured that NHS England have reflected upon the concerns raised in your report in relation to Ms Burman’s care.” Source location Response from DHSC
Open published response
21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Insufficient GP capacity to meet demand at HMP Cardiff View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alan Richard Miles Davies · 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 Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient GP capacity to meet demand at HMP Cardiff
Wider context from the report “(9) The number of GPs working in HMP Cardiff was insufficient to meet the demands upon them .
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand GP capacity through increased core-establishment funding, a local-practice service-level agreement and recruitment of additional GPs.
Verbatim wording from the response “Efforts to address GP recruitment challenges include increased funding to expand the core GP establishment and the initiation of a Service Level Agreement with a local GP Practice. Additional GPs have been recruited to support current Vacancies” Source location Response from Cardiff and Vale University Health Board
Open published response
12 Mar 2024 Elizabeth Jane Brown · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Insufficient qualified and trained immunology staffing View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Deliver the Long-Term Workforce Plan through strategic workforce planning and expanded domestic education, training and recruitment.
View source
NHS England
Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
View source
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AI-generated summary
Elizabeth Jane Brown · 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
Elizabeth Jane Brown had severe respiratory disease and was diagnosed with mesothelioma, which was attributed on the balance of probabilities to asbestos exposure; she died at Stepping Hill Hospital on 23 January 2023. The inquest heard concerns about lengthy delays in immunology follow-up, linked to a significant national shortage of qualified and trained staff and high vacancy levels.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient qualified and trained immunology staffing
Wider context from the report “The inquest heard evidence that Elizabeth Jane Brown had been referred to immunology services in 2018 due to low antibody levels and concerns about the overall impact on her health. A treatment plan was developed. She had an appointment on 4th February 2021 when the plan was that she should be followed up in 12 months’ time. She had not been seen again at the date of her death on 23rd January.
Such long waits and delays to see immunologists in specialist clinics were the inquest was told not unusual notwithstanding the role they could play in treating those in need of immunology services. The evidence before the inquest was that the reason for those delays was a significant shortage of qualified /trained staff nationally which had led to services across the country being run with a high level of vacancies . The position was not improving in terms of recruiting to vacant posts the inquest was told
” Source location Elizabeth Jane Brown · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver the Long-Term Workforce Plan through strategic workforce planning and expanded domestic education, training and recruitment.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
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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 Improve workforce culture, leadership and wellbeing to support staff retention in NHS employment.
Verbatim wording from the response “NHS England is also working at a national level to deliver the Long-Term Workforce Plan. This is a robust and effective strategy to ensure we have the right number of people, with the right skills and support in place to be able to deliver the kind of care people need. It heralds the start of the biggest recruitment drive in health service history, but also of an ongoing programme of strategic workforce planning. It includes ambitious commitments to grow the workforce by significantly expanding domestic education, training, and recruitment, as well as actions aimed at improving culture, leadership and wellbeing so that more staff are retained in NHS employment over the next 15 years.” Source location Response from NHS England
Open published response
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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 Trusts are responsible for ensuring safe staffing levels in the day-to-day operation of their hospitals.
Verbatim wording from the response “These actions will aim to close anticipated staffing shortfalls in the NHS in the long term, however Trusts have a responsibility to ensure safe staffing levels at local level in the current day to day operation of their hospitals. This is in line with Care Quality Commission (CQC) Regulation 18 which states that providers must deploy enough suitably qualified, competent and experienced staff to enable them to meet all other regulatory requirements.” Source location Response from NHS England
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.