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
Individual concerns: 89
Date range: 2013–2026
Stated actions: 154

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

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.

15 Feb2016
Surrey
Concerns raised1
1. Lack of prescribed safe nursing staffing levels for acute psychiatric wards
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Share revised National Quality Board staffing guidance with providers.
  Stated by Care Quality Commission and NHS EnglandStated planned
2. Action
  Introduce and use a care-hours-per-patient-day metric to assess trusts’ management of staffing resources.
  Stated by Care Quality Commission and NHS EnglandStated planned
Respondent positions 2
1. Position
  Responsibility for determining staffing numbers and skill mix rests with individual Trust boards, taking account of local circumstances.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Minimum staffing numbers or ratios would not guarantee safety because evidence is lacking and they would ignore local circumstances, skill mix and case mix.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Adam James Withers · 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

Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

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 prescribed safe nursing staffing levels for acute psychiatric wards
Wider context from the report
“At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients’ notes as they should. Further, Elgar Ward is an acute psychiatric ward with both detained and voluntary patients. It is foreseeable that reactive and unplanned interventions will be required at times and that the level of observation needed by each patient will fluctuate. The staffing levels on Elgar Ward were deemed sufficient for only a fixed number of patients to be subject to increased observation levels, and only one patient to be under constant observation, at any one time. I was informed that if more patients required increased or constant observation, additional staff would be needed but may not be readily available. I have been told by the Trust that no nationally prescribed safe staffing levels are in place for an acute psychiatric ward (whether based on patient to staff ratios or otherwise) and that the Trust considers its staffing levels to be in accordance with such guidelines as do exist. The Mental Health Taskforce’s recently published report entitled “The Five Year Forward View For Mental Health” does not appear to address this issue. It does seem that the absence of prescribed safe nursing staff levels for acute psychiatric wards could leave such wards unable to provide, throughout each shift, the level of patient supervision, observation and intervention needed. This could adversely affect the staff’s ability to protect their patients’ lives. ”
Source location
Adam James Withers · Prevention of Future Deaths report
Page 5 · 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
Share revised National Quality Board staffing guidance with providers.

Verbatim wording from the response
“So, we will jointly design the approach the CQC will use to assess trusts’ use of resources. We are also looking at how the CQC can use the financial data NHS Improvement holds and use the expertise of NHS Improvement staff in reaching its judgements on use of resources. Similarly, as NHS Improvement develops its view of the role of quality in the new, single, provider regulatory framework, we will do this jointly with the CQC and NHS England. We will also be sharing revised National Quality Board staffing guidance and a new metric looking at care hours per patient day that we will both use in looking at how trusts manage staffing resources.”

Source location
2016-0059-Response-by-Care-Quality-Commission
Page 2 · response
Published 15 February 2016
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 use a care-hours-per-patient-day metric to assess trusts’ management of staffing resources.

Verbatim wording from the response
“So, we will jointly design the approach the CQC will use to assess trusts’ use of resources. We are also looking at how the CQC can use the financial data NHS Improvement holds and use the expertise of NHS Improvement staff in reaching its judgements on use of resources. Similarly, as NHS Improvement develops its view of the role of quality in the new, single, provider regulatory framework, we will do this jointly with the CQC and NHS England. We will also be sharing revised National Quality Board staffing guidance and a new metric looking at care hours per patient day that we will both use in looking at how trusts manage staffing resources.”

Source location
2016-0059-Response-by-Care-Quality-Commission
Page 2 · response
Published 15 February 2016
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
Responsibility for determining staffing numbers and skill mix rests with individual Trust boards, taking account of local circumstances.

Verbatim wording from the response
“Responsibility for staffing rests (as it has always done) with Trust boards. Trusts’ staffing arrangements should enable the right numbers and skill mix of staff at the right time to deliver quality care and patient safety while doing so efficiently, taking into account local factors such as acuity, case mix and how to respond to fluctuations in workload.”

Source location
2016-0059-Response-by-Department-of-Health
Page 2 · response
Published 15 February 2016
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
Minimum staffing numbers or ratios would not guarantee safety because evidence is lacking and they would ignore local circumstances, skill mix and case mix.

Verbatim wording from the response
“We do not agree that a minimum staffing level for services would be a “guarantee for safety”: the evidence base is lacking and minimum staffing numbers and ratios would not take account of local circumstances, skill mix or case mix. Following publication of the revised guidance by NQB, further outputs will be developed by the national programme for individual settings including mental health and learning disability settings.”

Source location
2016-0059-Response-by-Department-of-Health
Page 3 · response
Published 15 February 2016
Open published response
6 Jul2015
Inner West London
Concerns raised1
1. Use of staff without appropriate qualifications to provide expert psychiatric referral advice
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mr Tommy Faegh Faisali · 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

Mr Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.

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
Use of staff without appropriate qualifications to provide expert psychiatric referral advice
Wider context from the report
“(1) That patients referred by their GP for second opinion from psychiatrists are not being seen by the same but rather by psychiatric health care staff with less qualification to diagnose and assess and recommend treatment then the GP who made the referral. (2) That a shortage of appropriately qualified doctors is being compensated for by staff without the appropriate qualifications to provide the expert advice being requested by GPs when they make psychiatric referrals. (3) Those patients may be at increased risk because of (1) and (2) above. ”
Source location
Mr Tommy Faegh Faisali · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Apr2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Howell Glyndwr Fisher · 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

Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.

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 for required one-to-one nursing observation of patients at high risk of falls
Wider context from the report
“(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered. ”
Source location
Howell Glyndwr Fisher · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Mar2015
Manchester South
Concerns raised1
1. Insufficient critical care nurse capacity for immediate High Dependency Unit transfer
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Maintain two critical care nurses on the Trafford site at all times for High Dependency Unit transfers and care.
  Stated by Manchester University NHS Foundation TrustStated completed
AI-generated summary

Bryan Herbert Whitby · 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

Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient critical care nurse capacity for immediate High Dependency Unit transfer
Wider context from the report
“7. The Inquest also heard evidence that Mr Whitby required transfer to the High Dependency Unit but this could not take place immediately as two critical care nurses were required and one had been sent to Manchester Royal Infirmary as was the practice if there were no patients in the HDU at the start of their shift. ”
Source location
Bryan Herbert Whitby · 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
Maintain two critical care nurses on the Trafford site at all times for High Dependency Unit transfers and care.

Verbatim wording from the response
“Since the date of the incident regarding the transfer of Mr Whitby to the High Dependency Unit, two Critical Care Nurses have been on site at Trafford at all times. The Critical Care Service has recently reviewed the use of Trafford's High Dependency Unit and is widening the scope for the type of patients who can be nursed there in the future. This means that not only will the Critical Care Nurses be based on the Trafford site – they will be based at all times on the High Dependency Unit.”

Source location
2015-0121-Response-by-Central-Manchester-University-Hospital
Page 3 · response
Published 25 March 2015
Open published response
19 Mar2015
Cardiff and Vale of Glamorgan
Concerns raised1
1. Insufficient staffing capacity for safe patient oversight
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Work with the Royal College of Physicians to agree staffing requirements and standards for managing medical outlier patients.
  Stated by Cardiff & Vale University LHBStated in progress
2. Action
  Maintain a process for covering short-term sickness and absence vacancies to protect staffing levels.
  Stated by Cardiff & Vale University LHBStated completed
3. Action
  Use cross-Clinical-Board medical staffing during extreme pressure to increase capacity in pressured areas.
  Stated by Cardiff & Vale University LHBStated in progress
1. Action
  Continue prioritising patient flow and monitoring multidisciplinary workload pressures, managing identified risks through the Risk Register.
  Stated by Cardiff & Vale University LHBStated in progress
AI-generated summary

Elsie May Hayward · 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

Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.

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 capacity for safe patient oversight
Wider context from the report
“1. On the 7th January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio. The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated falls. ”
Source location
Elsie May Hayward · Prevention of Future Deaths report
Page 1 · 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
Work with the Royal College of Physicians to agree staffing requirements and standards for managing medical outlier patients.

Verbatim wording from the response
“Currently there are no national recognised standards for medical staffing levels although this is currently being considered by the Royal College of Physicians (RCP) and the UHB will work with the RCP to agree staff requirements and standards for the medical management of patients who are outliers.”

Source location
2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 2 · response
Published 19 March 2015
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 a process for covering short-term sickness and absence vacancies to protect staffing levels.

Verbatim wording from the response
“• The Clinical Director for Internal Medicine has worked with the junior doctors, led by the Chief Resident (SpR) to agree a process for covering vacancies due to short term sickness/absence to ensure that staffing is not compromised”

Source location
2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015
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 cross-Clinical-Board medical staffing during extreme pressure to increase capacity in pressured areas.

Verbatim wording from the response
“• In times of extreme pressure, the Medical Director makes representation to all Clinical Boards to make sure that as many medical staff are undertaking generic medical duties as possible to increase capacity in areas which are under more pressure.”

Source location
2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015
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
Continue prioritising patient flow and monitoring multidisciplinary workload pressures, managing identified risks through the Risk Register.

Verbatim wording from the response
“Additionally the UHB continues to prioritise issues of patient flow and monitors workload pressures for the multi-disciplinary team and recognises associated risks. The Medicine Clinical Board (MCB) will continue to work with the UHB patient flow work stream in order to safely manage patient flow through the organisation. Risks identified will be managed via the Risk Register and acted upon accordingly.”

Source location
2015-0224-Response-by-Cardiff-Vale-University-Health-Board
Page 3 · response
Published 19 March 2015
Open published response
12 Mar2015
Nottinghamshire
Concerns raised1
1. Insufficient overnight ward staffing capacity for patient workloads
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Provide assessed enhanced one-to-one care day and night using ward, bank or agency staffing when additional resources are required.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
2. Action
  Implement the approved nursing staffing model of five registered and two unregistered staff by day and three registered and one unregistered staff by night.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
3. Action
  Drive a nurse recruitment strategy to recruit the registered nurses required for medical wards to adopt the new staffing model.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated in progress
1. Action
  Monitor staffing levels and their impact on quality and safety through the Trust Board and Quality Committee.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Medical wards cannot adopt proposed staffing levels until approximately 100 additional registered nurses are recruited, anticipated to take a further 12 months.
  Stated by Sherwood Forest Hospitals NHS Foundation TrustUnable to act
AI-generated summary

Mrs Elizabeth Ann Cox · 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 Elizabeth Ann Cox, who was 84 and had a high risk of falls, fell from her hospital bed on 18 July 2014 after the equipment accepted as necessary—a Hi-Lo bed and crash mats—had not been provided. Her condition deteriorated and she died at Kingsmill Hospital on 10 August 2014; the report found a clear link between the fall and her death. The report also raised concerns about insufficient night staffing and the lack of equivalent additional staffing support during night hours.

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 overnight ward staffing capacity for patient workloads
Wider context from the report
“The evidence of senior nursing staff involved with this ward and with the trust’s internal investigation made it clear that those working on the ward on the night of 17/18 July felt they needed further staff to cope with the demands of the patients they were looking after. We heard that the ward sister followed hospital protocol to request assistance. When it was clear that no one was available from neighbouring wards, a bank nurse was requested. Unfortunately, the bank nurse cancelled at very short notice. The duty nurse manager was called, but noone was available to assist at short notice. 1. During daytime hours, where additional staff are needed, the Reducing Harm Team can be contacted to provide the necessary resources. I was told, although this is currently under review, that,as matters stand, this (or an equivalent) is not available during the night. 2. It has been suggested as part of a trust-wide review that the number of staff available on the wards at night be reduced – from 3 registered and 2 unregistered currently, to 3 registered and 1 unregistered. I am aware that this is merely a proposal – and not currently in place – but should this come into effect, I am concerned that events like these may re-occur, where staff simply do not have the capacity to look after their patients safely, because of workloads. ”
Source location
Mrs Elizabeth Ann Cox · 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
Provide assessed enhanced one-to-one care day and night using ward, bank or agency staffing when additional resources are required.

Verbatim wording from the response
“1. A risk assessment form is completed on the ward identifying the level of enhanced care that is required.”

Source location
2015-0094-Response-by-Sherwood-Forest-Hospital
Page 2 · response
Published 12 March 2015
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 approved nursing staffing model of five registered and two unregistered staff by day and three registered and one unregistered staff by night.

Verbatim wording from the response
“New Investment Numbers: RN Days Numbers: 5 HCA Days Numbers: 2 RN Nights Numbers: 3 HCA Nights Numbers: 1 Overall Numbers: 5+2 Days; 3+1 Nights”

Source location
2015-0094-Response-by-Sherwood-Forest-Hospital
Page 4 · response
Published 12 March 2015
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
Drive a nurse recruitment strategy to recruit the registered nurses required for medical wards to adopt the new staffing model.

Verbatim wording from the response
“Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.”

Source location
2015-0094-Response-by-Sherwood-Forest-Hospital
Page 6 · response
Published 12 March 2015
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
Monitor staffing levels and their impact on quality and safety through the Trust Board and Quality Committee.

Verbatim wording from the response
“Requests for enhanced care and 1-1 support will continue to be supported when required. During this period of change the Trust Board and the Quality Committee continue to robustly monitor the staffing levels and the impact upon quality and safety.”

Source location
2015-0094-Response-by-Sherwood-Forest-Hospital
Page 6 · response
Published 12 March 2015
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
Medical wards cannot adopt proposed staffing levels until approximately 100 additional registered nurses are recruited, anticipated to take a further 12 months.

Verbatim wording from the response
“Our medical wards have not been as successful with nurse recruitment. This is a national problem but the Trust has developed and are currently driving a nurse recruitment strategy to recruit more Registered Nurses. Our medical wards, including the ward in which Mrs Cox was cared for, are currently being maintained on the post Keogh numbers as described below.”

Source location
2015-0094-Response-by-Sherwood-Forest-Hospital
Page 6 · response
Published 12 March 2015
Open published response
11 Mar2015
Manchester South
Concerns raised1
1. Insufficient junior doctor staffing to cover patient needs
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Review general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.
  Stated by Stockport NHS Foundation TrustStated in progress
2. Action
  Increase junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.
  Stated by Stockport NHS Foundation TrustStated planned
3. Action
  Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.
  Stated by Stockport NHS Foundation TrustStated planned
AI-generated summary

Neil Thomas Westerman · 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

Neil Thomas Westerman attended Stepping Hill Hospital for an elective cholecystectomy on 2 July 2014, after which a bile leak caused septicaemia. Concerns included the pre-operative assessment being conducted by a junior doctor, incomplete operation notes about equipment and materials, and insufficient junior doctors available in practice, particularly 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 junior doctor staffing to cover patient needs
Wider context from the report
“3. I heard evidence, as I have on previous occasions, that there were simply too few junior doctors on duty to cover the needs of the patients, especially at night. It was not suggested that the numbers were not in compliance with the set guidelines, but rather that in practice there simply weren’t enough doctors available. ”
Source location
Neil Thomas Westerman · Prevention of Future Deaths report
Page 1 · 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 general surgical junior doctor rotas, including surgical assessment unit presence and distribution across the working week.

Verbatim wording from the response
“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location
2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015
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 junior doctor presence on the surgical assessment unit and distribute doctors more evenly across the working week.

Verbatim wording from the response
“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location
2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015
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
Consider broadening advanced nurse practitioner roles to undertake basic junior doctor duties.

Verbatim wording from the response
“Despite numbers being in compliance with set guidelines, there were too few junior doctors on duty to cover the needs of the patients. We are currently undertaking a review of the general surgical junior doctor rotas; this will include increased presence on the surgical assessment unit and a more even spread of doctors throughout the working week. Consideration is also being given to broadening the advanced nurse practitioner roles; these nurses have the competencies and skills to carry out many of the basic junior doctor roles. The plan is to have these changes in place by the end of August 2015.”

Source location
2015-0091-Response-by-Stockport-NHS-Trust
Page 1 · response
Published 11 March 2015
Open published response
2 Mar2015
Staffordshire South
Concerns raised1
1. Insufficient ward staffing for the patient workload
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Conduct nurse staffing establishment reviews at least every six months using quality, workload and professional-judgment data, with recommendations reviewed by the Trust Board.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
2. Action
  Provide Brocton Ward with a minimum staffing establishment of four, four and three, including two registered nurses on duty at all times, and deploy additional staff when acuity increases.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
3. Action
  Provide non-nursing clinical staff on the ward to undertake duties including therapeutic interventions.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing staffing reviews, minimum ward establishments and additional staff deployment are considered sufficient to manage patient acuity and staffing needs.
  Stated by Midlands Partnership University NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Peter Jonathan Wright · 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 Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

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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 staffing for the patient workload
Wider context from the report
“(1) At the time of the death the ward was understaffed. Of the quota staff of three, one care assistant had been called to assist in another ward (and had in fact just returned) and one care assistant was with another patient who required continuous observation. This left just the qualified nurse to deal with 16 patients. She did not record all necessary observations and was doing a drugs round by herself (contrary to policy). This was recognised in the SIR carried out by ████████ but no recommendation was made about it on the basis that the Trust was undergoing a major staffing review in any event. It may therefore be that the situation has already been addressed but this was not clear to me at the Inquest and the impression I received from the nurse was that there is now some extra support at times but it is still not satisfactory. ”
Source location
Peter Jonathan Wright · Prevention of Future Deaths report
Page 1 · 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
Conduct nurse staffing establishment reviews at least every six months using quality, workload and professional-judgment data, with recommendations reviewed by the Trust Board.

Verbatim wording from the response
“The Trust undertakes nurse staffing establishment reviews for each of our in-patient ward areas on at least a six-monthly basis. In undertaking these reviews, the Trust uses:”

Source location
2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
Page 1 · response
Published 2 March 2015
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 Brocton Ward with a minimum staffing establishment of four, four and three, including two registered nurses on duty at all times, and deploy additional staff when acuity increases.

Verbatim wording from the response
“For 2015/16 Brocton Ward staffing establishment is 4/4/3 (with two registered nurses on duty at all times). This is the minimum level which can be expected on the ward”

Source location
2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
Page 1 · response
Published 2 March 2015
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 non-nursing clinical staff on the ward to undertake duties including therapeutic interventions.

Verbatim wording from the response
“with additional staff being deployed to meet any increased acuity. There are also non-nursing clinical staff who will be present on the ward undertaking other duties – examples will include medical and allied health professionals providing therapeutic interventions.”

Source location
2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
Page 2 · response
Published 2 March 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing staffing reviews, minimum ward establishments and additional staff deployment are considered sufficient to manage patient acuity and staffing needs.

Verbatim wording from the response
“The Trust undertakes nurse staffing establishment reviews for each of our in-patient ward areas on at least a six-monthly basis. In undertaking these reviews, the Trust uses:”

Source location
2015-0073-Response-by-South-Staffordshire-Shropshire-Healthcare-NHS-Trust1
Page 1 · response
Published 2 March 2015
Open published response
20 Feb2015
Carmarthenshire & Pembrokeshire
Concerns raised1
1. Insufficient staffing resources on the acute ward
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Increase ward staffing to a minimum of four staff per shift, with flexible additional cover and escalation arrangements for increased need.
  Stated by Hywel Dda University LHBStated completed
AI-generated summary

Laura 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

Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

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 resources on the acute ward
Wider context from the report
“(2) Staffing levels on the Ward need to be reviewed as it was felt that staffing resources were stretched at the relevant time (1 nurse and 3 support workers on a 16 bed acute ward). ”
Source location
Laura Hill · 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 ward staffing to a minimum of four staff per shift, with flexible additional cover and escalation arrangements for increased need.

Verbatim wording from the response
“Since the incident occurred, the ward has reviewed (May 2013) the shift pattern and now works on the basis of four staff as a minimum per shift, with an additional staff member on a flexible shift to cover the busier part of the day. This covers 10 nursing staff only. Additionally, the ward would have the manager and other disciplines providing input. Staffing levels have to be flexible and dependant upon patient acuity and complexity. This requires increasing staffing levels at short notice, particularly where one to one observations are required. There are systems in place on a twenty four hour basis to sanction increased staffing levels when they are required.”

Source location
2015-0092-Response-by-University-Health-Board
Page 2 · response
Published 20 February 2015
Open published response
17 Nov2014
Manchester South
Concerns raised1
1. Insufficient qualified ward staffing capacity for patient workload and complexity
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Monitor staffing levels and skill mix through daily reporting, assurance processes, escalation arrangements and senior nursing support.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
3. Action
  Assess staffing through ward-based accreditation and unannounced walk rounds.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Ward 41 staffing levels met national guidelines, although the ward was busy and further action addressed agency use and substantive vacancies.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concern
AI-generated summary

Elsie Mallalie u · 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 Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to 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 qualified ward staffing capacity for patient workload and complexity
Wider context from the report
“4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”
Source location
Elsie Mallalie u · Prevention of Future Deaths report
Page 1 · 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
Reduce agency-staff use, address substantive vacancies and maintain registered nursing levels.

Verbatim wording from the response
“Response The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor staffing levels and skill mix through daily reporting, assurance processes, escalation arrangements and senior nursing support.

Verbatim wording from the response
“Nurse staffing levels are being monitored through multiple assurance sources including the Trust Board Hard Truths paper. Additionally, the Trust’s Board is actively monitoring staff levels and the skill mix across the Trust. This involves staff levels being considered daily alongside daily staffing level reports and bed management, which involves the Deputy Director of Nursing. There is also a focus on reporting low staffing levels following which there is an escalation process involving the individual nurse in-charge, the senior nurse, the Divisional Head of Nursing and the Director of Nursing. This will also enable senior nurse intervention and support where required.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assess staffing through ward-based accreditation and unannounced walk rounds.

Verbatim wording from the response
“Staffing is also being assessed as part of ward based accreditation and unannounced walk rounds.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ward 41 staffing levels met national guidelines, although the ward was busy and further action addressed agency use and substantive vacancies.

Verbatim wording from the response
“Response The staffing levels on Ward 41 did indeed meet the national guidelines. The ward was staffed with auxiliary staff in addition to the two qualified nursing staff. However, since Mrs Mallalieu was treated the Trust have taken further action to reduce the use of agency staff and address substantive vacancies and ensure Registered Nursing levels are maintained.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 3 · response
Published 17 November 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of prescribed safe nursing staffing levels for acute psychiatric wards

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Use of staff without appropriate qualifications to provide expert psychiatric referral advice

Concerns raised1

Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls

Concerns raised1

Insufficient critical care nurse capacity for immediate High Dependency Unit transfer

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Insufficient staffing capacity for safe patient oversight

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised1

Insufficient overnight ward staffing capacity for patient workloads

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

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

Concerns raised1

Insufficient junior doctor staffing to cover patient needs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Insufficient ward staffing for the patient workload

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

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

Actions described in response 2

Respondent positions 2

Actions described in response 1

Actions described in response 4

Actions described in response 4

Respondent positions 1

Actions described in response 3

Actions described in response 3

Respondent positions 1