Recurring concern

Insufficient qualified healthcare staffing capacity

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First reported 30 Jul 2013•Latest report 1 Jun 2026

Definition

What this concern includes

Includes recurring shortages or inadequate deployment of qualified healthcare staff, including nursing cover, unsafe clinical caseloads, required one-to-one nursing care and specialist clinical staffing capacity.

Not included

  • Administrative, social-care or other non-healthcare staffing shortages
  • Competence or training failures where the number and deployment of qualified staff are sufficient
  • A single temporary absence that does not evidence a continuing capacity control
  • Named specialty capacity failures where a narrower retained parent directly captures the supported service boundary
Reports
85

Distinct published reports

Individual concerns
89

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
154

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.

NHS England12
Department of Health and Social Care11
Care Quality Commission7
Tameside and Glossop Integrated Care NHS Foundation Trust4
Barts Health NHS Trust3
Betsi Cadwaladr University LHB3
Manchester University NHS Foundation Trust3
Stockport NHS Foundation Trust3
Swansea Bay University Local Health Board3
University Hospitals Sussex NHS Foundation Trust3
Aneurin Bevan University LHB2
Cardiff & Vale University LHB2
Cwm Taf Morgannwg University Local Health Board2
Essex Partnership University NHS Foundation Trust2
Mid and South Essex NHS Foundation Trust2

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. Gwent

    AI-generated summary

    Elizabeth Robinson · 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 Robinson, an 87-year-old woman at Ysbyty Ystrad Fawr for rehabilitation after hip surgery, fell and sustained a fatal head injury on 21 October 2019. Concerns included inadequate falls-risk assessment and documentation, staffing levels that nurses considered insufficient to deliver safe care, and nursing staff not having seen the internal investigation findings more than a year after her death.

    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

    Insufficient nursing staffing levels for delivery of safe patient care

    Wider context from the report

    “1. Staffing Levels Aneurin Bevan University Health Board undertook an internal investigation which was presented at the inquest by ████████ and ████████ confirmed that Mrs Robinson had not been correctly assessed and warranted a higher level of supervision to minimise the risk of her falling. Whilst the documentation was not completed, two nurses gave evidence and I was reassured that they both understood that Mrs Robinson was at high risk of falls and were monitoring her as closely as possible with the staffing complement available. I was informed that on the ward at YYF there were usually 3 members of nursing staff to care for 15 patients. Mrs Robinson was in a cohorted group which meant that 1 member of staff was assigned to observe a group of 4 patients at all times. This left 2 nurses for the remaining 11 patients. The nurses who gave evidence both told me that they rarely managed to get their full breaks (40 minutes in a 12 hour shift) and were constantly in a position where they did not feel they could deliver a safe standard of care to the patients. Mrs Rowlands confirmed that staffing levels were not considered during the investigation and it was further confirmed that these apparently low staffing levels still exist. ”

    Source location

    Elizabeth Robinson · 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

    Review Community Ward establishments against patient acuity, dependency and quality metrics to determine whether staffing levels are fit for purpose.

    Verbatim wording from the response

    “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.”

    Source location

    2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 2 · response
    Published 23 March 2021

    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

    Complete an acuity audit and triangulated recalculation to determine appropriate nurse staffing levels on Ysbyty Ystrad Fawr Community Wards.

    Verbatim wording from the response

    “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.”

    Source location

    2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 2 · response
    Published 23 March 2021

    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

    Capture patient acuity data to determine workforce requirements.

    Verbatim wording from the response

    “A very recent triangulated approach to review Community Ward establishments in YYF has been undertaken by the Head of Nursing for Nevill Hall Hospital (NHH) and YYF. The purpose of this is to review the current ward establishments and determine if they are fit for purpose to meet the acuity and dependency of patients, considering all available quality metrics to inform and support additional requirements. In line with the Nursing Staff Levels (Wales) Act 2016 (NSLWA), a full acuity audit will take place during the month of June. This will provide essential intelligence to support a triangulated re-calculation in August 2021, to determine appropriate nurse staffing levels on all Community Wards in YYF. YYF has been proactive in its approach to determine patients’ acuity and commenced acuity capture as of April 2021 to determine workforce requirements.”

    Source location

    2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 2 · response
    Published 23 March 2021

    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

    The planned nursing roster was met, and the requested additional staffing for enhanced care was escalated and filled when the fall occurred.

    Verbatim wording from the response

    “Aneurin Bevan University Health Board (ABUHB) has processes in place across its sites to escalate any staffing deficits within a planned roster and/or any requests for additional staffing requirements. At the time of Mrs Robinson’s fall, a Nurse Staffing Escalation Policy (NSEP) was in place. This articulates everyone’s responsibility to maintain appropriate nurse staffing levels and sets clear actions if there is a deviation from what is required. Having reviewed the roster on the night of 20-21 October 2019, when Mrs Robinson fell on Oakdale Ward, it is noted that the planned nursing roster was met.”

    Source location

    2021-0072-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 1 · response
    Published 23 March 2021

    Open published response
  2. Mid Kent and Medway

    AI-generated summary

    Rodney Gates · 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

    Rodney Gates, aged 84, was struck by an HGV while crossing a road and sustained a fracture of the right proximal femur. He deteriorated from bleeding while on a hospital ward and died on 6 April 2018 despite treatment and resuscitation attempts. Concerns included missed clinical observations, low nursing staffing levels, reliance on agency nurses, limited staff experience and skills, and insufficient equipment.

    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

    Insufficient nursing staff numbers in A&E and on the ward

    Wider context from the report

    “(2) the overall low number of nursing staff both within the A&E department and on the ward ”

    Source location

    Rodney Gates · 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

    Complete a safe nursing-staffing review and resource increased nursing establishments in line with national guidelines.

    Verbatim wording from the response

    “• In 2019, the Chief Nursing Officer commissioned a safe nursing staffing review which identified and resourced increases in the establishment of nursing staff line in accord with national guidelines”

    Source location

    2021-0070-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 12 March 2021

    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 best-practice workforce tools annually to assess and maintain safe nursing staffing levels in Accident and Emergency.

    Verbatim wording from the response

    “• The Accident and Emergency department has used best practice workforce tools on an annual basis to ensure safe nursing staffing levels are met since 2017.”

    Source location

    2021-0070-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 12 March 2021

    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

    Develop a stable, experienced ward nursing team through recruitment and training to reduce agency-staff reliance.

    Verbatim wording from the response

    “• There is an experienced Ward Manager in post since 2018, who has developed a stable and experienced team with considerable consistent success in recruitment and training reducing agency usage in this area”

    Source location

    2021-0070-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 12 March 2021

    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

    Establish a Pembroke Ward nursing establishment including five experienced and trained Band 6 registered nurses.

    Verbatim wording from the response

    “• The reviewed establishment for nursing staff in Pembroke ward which now includes 5 x band 6 Registered Nurses, all with experience and training in orthopaedic nursing has significantly improved the specialised care delivery to patients and supervision of junior nursing staff.”

    Source location

    2021-0070-Response-from-Medway-Maritime-Hospital-Redacted
    Page 2 · response
    Published 12 March 2021

    Open published response
  3. Gwent

    AI-generated summary

    Alan Jones · 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 Jones was admitted to Neville Hall Hospital after a fall at home and, during his admission, fell seven times. On 13 November 2019 he fell while he should have been under constant supervision, suffered a fatal head injury, and died the following day. Concerns included inadequate multidisciplinary management of his falls risk, failure to provide the required supervision, and unsafe staffing levels.

    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

    Unsafe ward staffing levels failing to account for fluctuations in patient acuity

    Wider context from the report

    “1:1 Supervision Throughout Mr Jones’ admission I heard evidence that he required either 1:1 supervision (Enhanced Care Level 5) or to be supervised in a cohorted bay (Enhanced Care Level 4). This level of care was not achieved and as a result within less than 3 weeks of his admission, Mr Jones had fallen on 7 occasions, at times as a direct result of a failure to provide adequate supervision. I am satisfied that the nursing staff were aware of the level of supervision required and regularly requested additional nursing support. These requests were not resourced. It appears that the nursing staff had become used to this situation and tried to do the best they could in the circumstances. It also appeared that a ward which cares for patients who are the most likely to require extra support because they are confused, elderly and at risk of falls, is staffed to a minimum level which does not take account of any fluctuations in acuity. Of concern was that despite hearing evidence that improvements in falls management had been introduced, I also heard evidence that nursing staff on the ward continue to find themselves nursing with unsafe levels of staff. ”

    Source location

    Alan Jones · 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

    Increase the substantive Health Care Support Worker workforce to support enhanced care and continuity.

    Verbatim wording from the response

    “previously identified a need for an increase in Health Care Support Worker’s to support enhanced care by night and as a consequence the substantive HCSW workforce was increased to support this requirement.”

    Source location

    2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 4 · response
    Published 30 March 2021

    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

    Introduce and embed the multidisciplinary core care team model, including assistant practitioners, roster creators and ward assistants.

    Verbatim wording from the response

    “In 2019, on the backdrop of significant vacancies, circa 350 Whole Time Equivalent (WTE), it was imperative that the Health Board considered new roles and responsibilities for acute wards, promoting the principle of the ‘Prudent Registered Nurse’ with emphasis on appropriate and safe delegation practices. The core care team model was introduced as a result of a collaborative approach between Divisional and Corporate Nursing together with Workforce and Organisational Development. Ward 4/1 was identified as an ideal ward to embed this new model due to the dependency of the patients cared for, hence the recalculation undertaken in September 2019 incorporated the core care team model. The core care team comprised of several different roles, to include:”

    Source location

    2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 4 · response
    Published 30 March 2021

    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

    Maintain registered-nurse and Health Care Support Worker pools on acute sites to support staff deployment.

    Verbatim wording from the response

    “The establishment of Registered Nurse and HCSW pools on each acute site to support deployment of staff – taking all reasonable steps to ensure planned rosters were maintained on a backdrop of significant absenteeism and fluctuation in capacity required to manage the pandemic.”

    Source location

    2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 5 · response
    Published 30 March 2021

    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

    Some temporary staffing requests could not be filled despite escalation and other reasonable steps to address identified nurse staffing deficits.

    Verbatim wording from the response

    “Clear processes are in place within the Health Board to escalate any staffing deficits with the planned roster and/or any requests for additional staffing requirements. At the time of Mr Jones’ fall the Health Board had in place a Nurse Staffing Escalation Policy which articulates everyone responsibility, from Ward to Board, in maintaining appropriate nurse staffing levels and sets out clear actions if there is a deviation from what is required. In addition, daily site meetings occur to manage nurse staffing levels, consider any deficits, manage and identify any potential risks and escalate any supplementary requirements to the Resource Bank. There is clear evidence, by way of ‘Healthroster’, to indicate there was a recognition and identified need to increase nurse staffing levels to manage enhanced care on many occasions throughout Mr Jones’s admission.”

    Source location

    2021-0079-Response-from-Aneurin-Bevan-University-Health-Board-Redacted
    Page 3 · response
    Published 30 March 2021

    Open published response
  4. Manchester South

    AI-generated summary

    Evelyn Ross · 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

    Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

    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

    Lack of sufficient and appropriately experienced ward staffing

    Wider context from the report

    “1. The inquest was told that the ward in question had been short staffed for a number of months. As a result there was a reliance on agency staff and less experienced staff. The trust was now seeking to resolve the issue but it was still not fully resolved. It reflected a wider issue of a national shortage of nurses. ”

    Source location

    Evelyn Ross · 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

    Develop and improve NHS-owned staff banks, including collaborative banks, to provide flexible staffing and reduce agency reliance.

    Verbatim wording from the response

    “We recognise that to fully eliminate unnecessary agency spending, the Department and the NHS need to support trusts in developing a viable alternative source of flexible staffing in the form of in-house Staff Banks. Having reduced the rate of agency spending, we are now entering a new phase of work, focusing on the creation and improvement of staff banks, wherein existing NHS staff, who choose to work flexibly, can do so through an NHS owned bank, as opposed to a privately-owned agency. In the context of staff shortages in the NHS, in-house staff banks, and especially collaborative banks, create a larger pool of flexible staff, ensuring better quality and continuity of care, and reducing unnecessary agency spending by avoiding expensive commission.”

    Source location

    2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Deliver 50,000 additional NHS nurses by 2025 through expanded training, recruitment and retention.

    Verbatim wording from the response

    “However, we of course accept we need to do more and that is why on 18 December 2019, the Government announced a commitment to deliver 50,000 more nurses in our NHS by 2025. We will do this through a combination of investing in and diversifying our training pipeline, as well as recruiting and retaining more nurses in the NHS.”

    Source location

    2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Provide financial support grants to eligible nursing, midwifery and allied health professional students, including additional support for childcare and shortage areas.

    Verbatim wording from the response

    “This Government has already taken steps to deliver this commitment through our recently announced financial support package for eligible students. Eligible pre-registration nursing, midwifery and most allied health professional students on courses at English universities from September 2020 will benefit from grants of at least £5,000 per academic year. There will be up to £3,000 additional funding for some students to help with childcare costs or who choose to study in regions or specialisms struggling to recruit, including with priority given to shortage groups that are key to delivering the NHS Long Term Plan². None of this funding will have to be paid back.”

    Source location

    2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Recruit registered and unregistered nurses, appoint Ward 6 leadership and patient-flow staff, and recruit additional Nursing Assistants to strengthen staffing capacity.

    Verbatim wording from the response

    “Since April 2019, a number of International Recruitment (IR) Registered Nurses have been recruited to wards at Trafford General Hospital in addition to successful domestic recruitment to Registered Nursing posts across Trafford General Hospital. A substantive appointment was made for a new Ward Manager that joined the team in January 2020, in addition four experienced Band 6 Registered Nurses have been appointed to Ward 6 specifically. A Band 3 Patient Flow Coordinator role has also been developed and successfully appointed to on Ward 6.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Review Ward 6 workforce establishments and progress collaborative workforce redesign with therapy leads to align staffing and skill mix with rehabilitation needs.

    Verbatim wording from the response

    “The Trust has an established process in place to review nursing workforce establishments and skill mix for all wards. This utilises an evidence-based triangulated approach to determine safe staffing levels and skill mix, that reflect patient acuity and dependency requirements to inform workforce planning. The Safer Nursing Care Tool (SNCT) is utilised to gather patient acuity and dependency data over a four-week period. Ward 6 completed data collection periods in March, June and September 2019 and January 2020. The outcome of this data collection was utilised to inform the establishment review process, which was completed for Ward 6 in March 2020. Further workforce redesign is being progressed collaboratively with Therapy Leads for Ward 6, to reflect the requirements of the rehabilitation service at Trafford General Hospital.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Provide enhanced induction and senior nursing support for new and temporary staff, including local clinical-area induction.

    Verbatim wording from the response

    “Induction for new recruits is provided on the Trafford General Hospital site, and the Head of Nursing now supports this with the welcome and introduction session. This provides an additional opportunity for staff to engage with Senior Nurses who give feedback and provide ongoing support.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 2 · response
    Published 5 June 2020

    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

    Review out-of-hours skill mix and training needs and coordinate regular senior nursing deployment meetings with escalation of staffing concerns.

    Verbatim wording from the response

    “A review of the skill mix and roles and a Training Needs Analysis for the Out of Hours team has also been undertaken. This is to ensure that the clinical contribution is maximised, and the correct level of professional leadership is provided to teams at Trafford General Hospital in the out of hours period.”

    Source location

    2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
    Page 3 · response
    Published 5 June 2020

    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

    Individual NHS trusts are responsible for determining staffing numbers, staff types and agency staff use.

    Verbatim wording from the response

    “Individual NHS Trusts are responsible for the number and type of staff they employ and they must ensure that there are sufficient staff and that those staff are trained and competent to carry out their duties. This applies equally to the usage of agency staff, which is a local decision for individual employers.”

    Source location

    2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 5 June 2020

    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

    Health Education England leads national workforce education, training and workforce supply arrangements.

    Verbatim wording from the response

    “In terms of the health and care workforce overall, Health Education England (HEE) provides leadership for the education and training system at a national level. HEE ensures that the workforce has the right skills, behaviours and training, and is available in the right numbers.”

    Source location

    2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 2 · response
    Published 5 June 2020

    Open published response
  5. East London

    AI-generated summary

    Mrs Ibiyemi Ereohah · 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 Ibiyemi Ereohah attended hospital with abdominal pain and anaemia, and investigations concerning a possible sarcoma were followed by delays and deficiencies in assessment and surgical planning. She underwent a hysterectomy on 30 August 2018 and was subsequently diagnosed with a high-grade uterine sarcoma; she died from metastatic leiomyosarcoma on 17 September 2018. The substantive concerns included inadequate gynae-oncology consultant cover and a delayed consultant review of her fitness for surgery.

    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

    Insufficient gynae-oncology consultant cover

    Wider context from the report

    “1. Many of the concerns arising in this case were considered to be due to an insufficiency of gynae-oncology consultant cover at Newham University hospital. The lack of adequate Consultant cover was deemed to have contributed to the lack of advocacy at the MDT meeting; the inability to challenge the MDT conclusion and the lack of Consultant overview of the recurrent admissions. In July 2019, the Trust agreed two key actions to address this deficiency: • Clinical Leads at the RLH and NUH to review gynaecological oncology staffing and job planning, to ensure adequate administration time; cover when on leave/programmed for other duties, such as hot weeks. • There should be an urgent organisational development/service level review of the NUH gynae-oncology team that is independent of the site. As at the date of the Inquest, neither of these necessary actions had been completed. ”

    Source location

    Mrs Ibiyemi Ereohah · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  6. Nottinghamshire

    AI-generated summary

    Evelyn Ann Swift · 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

    Evelyn Ann Swift became increasingly unwell over several days and contacted her GP surgery repeatedly on 3 January 2019, but a home visit was not arranged until that evening. The assessment was incomplete, her condition was not recognised as severe, and she was not admitted to hospital; she was found deceased at home the following morning. The principal concerns related to unsafe procedures for triage, home-visit allocation, urgent clinical advice, documentation, clinical cover, and review of significant events.

    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

    Insufficient clinical capacity for safe cover at each service location

    Wider context from the report

    “5. The Beechdale Group did not have sufficient clinical capacity to ensure safe clinical cover arrangements at each location where services are provided. ”

    Source location

    Evelyn Ann Swift · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Manchester West

    AI-generated summary

    Robert Charles Rostron · 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

    Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.

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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

    Absence of another qualified nurse when an agency nurse is on duty

    Wider context from the report

    “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time. ”

    Source location

    Robert Charles Rostron · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. South Wales Central

    AI-generated summary

    Jenson James Francis · 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

    Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.

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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 staffing capacity for patient acuity

    Wider context from the report

    “(5) There were insufficient staffing levels, and very high acuity, despite which there was no consultant attendance and the escalation policy was not used. There was evidence that there was no clear line of responsibility for identifying this and ameliorating it. ”

    Source location

    Jenson James Francis · 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

    Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.

    Verbatim wording from the response

    “Staffing has significantly improved since August 2018 with ongoing recruitment of midwifery staff. The merger of the two units has assisted in managing any staffing shortfalls as we are no longer providing cover for two units.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 2 · response
    Published 28 July 2019

    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

    Complete a Birth Rate Plus assessment of workforce needs for the new unit.

    Verbatim wording from the response

    “Midwifery and medical staffing are being reported on a monthly basis via the Maternity Improvement Board. We are currently undergoing a Birth Rate Plus Assessment of our workforce needs in the new unit. The final assessment report will be available in September 2019.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 3 · response
    Published 28 July 2019

    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

    Increase consultant cover through recruitment of three consultants and provide 60-hour labour-ward presence.

    Verbatim wording from the response

    “Consultant cover has increased significantly and the Health Board has recently recruited 3 new consultants. There is 60 hour labour ward presence on the labour ward since the merger.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 3 · response
    Published 28 July 2019

    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

    Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.

    Verbatim wording from the response

    “Birthrate plus acuity system for labour ward has been implemented into the unit and staff are currently being supported to use this to support timely escalation.”

    Source location

    2019-0158-Response-by-University-Health-Board
    Page 3 · response
    Published 28 July 2019

    Open published response
  9. Brighton and Hove

    AI-generated summary

    Ioannis AVGOUSTI · 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

    Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

    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

    Insufficient nursing and medical staffing capacity

    Wider context from the report

    “(3) On the same night the nurses and the doctors were working 12½ hour “weekend” shifts”. The day nursing shift was one nurse short and so far as the doctors were concerned they were, as I understand they always are at weekends, too few in number and as a result all staff in hospital are thoroughly stretched and stressed and under resourced. This is no way to run a hospital service. Exacerbating factors in Mr. Avgousti’s case were that his rapid deterioration took place at around handover for both doctors and nurses, thus adding even more pressure to the situation. ”

    Source location

    Ioannis AVGOUSTI · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  10. South Wales Central

    AI-generated summary

    Calary Fern Davis · 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

    Calary Fern Davis was delivered by emergency Caesarean Section on 31st December 2017 after fetal bradycardia caused hypoxic ischaemic encephalopathy and very serious brain damage, and she later died from that condition. The report identified concerns about failures in the induction pathway, including a lack of planned obstetric review, delay in artificial rupture of membranes, insufficient staffing and leadership, poor communication and safety briefings, and a culture against performing artificial rupture of membranes at night.

    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

    Insufficient staffing levels

    Wider context from the report

    “(8) There were insufficient staffing levels, despite which the escalation policy was not used. ”

    Source location

    Calary Fern Davis · 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

    Recruit additional midwives through continuous advertising while monitoring staffing levels through the Assurance Board.

    Verbatim wording from the response

    “7. There were insufficient staffing levels, despite which, the escalation policy was not used. Staffing has significantly improved since August 2018. We have a rolling advert for recruitment of midwives and this is monitored closely. The merger of the two units assists with the difficulties of the shortfall. Currently the Health Board has a vacancy of 15 WTE Midwives with midwifery staffing now at 90% of the required midwifery levels for the service. Staffing is monitored weekly through our Assurance Board and a Senior Midwife on call rota is in place and was implemented in July 2018. Please refer also to point 5.”

    Source location

    2019-0043-Response-by-University-Health-Board
    Page 3 · response
    Published 24 May 2019

    Open published response
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Data last updated 7 September 2026