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.

7 Oct2014
North Wales (East and Central)
Concerns raised2
1. Failure to provide Acute Liaison Nurse cover during staff absence
2. Insufficient Acute Liaison Nurse staffing capacity
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.

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

Timothy Peter Cowen · 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

Timothy Peter Cowen underwent surgery on 23 April 2013 and subsequently developed bilateral extensive pneumonia with features of aspiration. He died on 2 May 2013 after deterioration and readmission to hospital. Concerns included non-mandatory training on new procedures and insufficient cover for Acute Liaison Nurses during absence.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide Acute Liaison Nurse cover during staff absence
Wider context from the report
“2. That whilst there has been established a new role of Acute Liaison Nurse to provide cohesion to the care given to patients requiring additional support, there are only three such ALNs and there is no cover in place when they are absent through illness or holidays. ”
Source location
Timothy Peter Cowen · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient Acute Liaison Nurse staffing capacity
Wider context from the report
“2. That whilst there has been established a new role of Acute Liaison Nurse to provide cohesion to the care given to patients requiring additional support, there are only three such ALNs and there is no cover in place when they are absent through illness or holidays. ”
Source location
Timothy Peter Cowen · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Sep2014
Carmarthenshire and Pembrokeshire
Concerns raised1
1. Insufficient provision of nursing staff when patient circumstances require greater staffing levels
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.

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

Mr Page · 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 Page was admitted to hospital after a fall, underwent surgery, and later fell from his bed, fracturing his cervical spine; his condition deteriorated and he died on 2 May 2014. Concerns included the absence of a falls risk assessment and low bed, communication needs after handover, and the provision of sufficient nursing staff when greater staffing levels were required.

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 provision of nursing staff when patient circumstances require greater staffing levels
Wider context from the report
“4. A review of the provision of nursing staff was identified when patient circumstances require greater staffing levels. ”
Source location
Mr Page · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Sep2014
Inner North London
Concerns raised1
1. Insufficient continuous nursing cover on the ward
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.

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

Thomas Charles TAYLOR · 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

Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

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 continuous nursing cover on the ward
Wider context from the report
“1. The ward where Mr Taylor was being nursed seemed rudderless, operating without clarity of leadership or support. On 21 February, a bank nurse worked alone in the morning, though was joined by another agency nurse at lunch time, with only a senior nurse in the office. On 22 February, the nurse in charge appeared unclear that he had any additional responsibility by virtue of being the nurse in charge, other than to allocate nurses to patients. Despite only three nurses being on duty on 22 February, the nurse in charge took a break at the same time as another nurse. There was a conflict of views among the nurses that day about who had primary care of Mr Taylor. ”
Source location
Thomas Charles TAYLOR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
26 Aug2014
South Lincolnshire
Concerns raised1
1. Insufficient nursing staffing capacity
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

Iris May GRIMWOOD · 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

Iris May GRIMWOOD, aged 80, died at Pilgrim Hospital on 8 October 2013 as a result of progressive neurological disease. Concerns were raised about difficulties providing the nursing care she needed, including errors in using semi-automatic thermometers and an attempted application of an antifungal ointment prescribed for oral thrush to her genital region.

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 capacity
Wider context from the report
“Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush, before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training. ”
Source location
Iris May GRIMWOOD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Jul2014
South and East Cumbria
Concerns raised1
1. Unrealistic school nurse service workload expectations
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 4
1. Action
  Fund three additional posts within the School Nursing Service to increase capacity.
  Stated by Cumbria County CouncilStated completed
2. Action
  Complete a case audit of safeguarding and child protection arrangements within the School Nursing Service.
  Stated by Cumbria County CouncilStated completed
3. Action
  Work with Cumbria Partnership Foundation Trust to make necessary changes within the School Nursing Service under the existing contract.
  Stated by Cumbria County CouncilStated in progress
1. Action
  Build necessary School Nursing Service changes into the specification for commissioning from October 2015.
  Stated by Cumbria County CouncilStated planned
AI-generated summary

Helena Kathleen Farrell · 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

Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

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
Unrealistic school nurse service workload expectations
Wider context from the report
“(4) As far as Cumbria County Council is concerned, they are involved because I understand they are responsible for provision of the school nurse service although they contract this out to the Partnership Trust but nonetheless the responsibility lies with Cumbria County Council. I thought that the expectations of the school nurse in this particular case were totally unrealistic. I heard in evidence that she was responsible for 5 senior schools and 20 or more feeder schools to those 5 senior schools and although the total number of pupils involved was not clear, it is obviously thousands rather than hundreds. She worked a 26 hour week, had 40 current cases at Kirkbie Kendal School alone. The provision of service at this level is totally unfair on the school nurse concerned, unrealistic in the sense that she seems to have expectations of a school nurse which one part time provider cannot meet. ”
Source location
Helena Kathleen Farrell · 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
Fund three additional posts within the School Nursing Service to increase capacity.

Verbatim wording from the response
“Recognising the immediate pressure on the School Nursing Service, since April 2013 the Council has funded a further three posts within the service. However this has always been seen as a short term solution to relieve pressure while a more fundamental review of the service is undertaken.”

Source location
2014-0309-Response-by-Cumbria-County-Council
Page 2 · response
Published 3 July 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Complete a case audit of safeguarding and child protection arrangements within the School Nursing Service.

Verbatim wording from the response
“Your findings, together with the Cumbria Partnership Foundation Trust Serious Untoward Incident Report and the Serious Case Review Report, indicate a problem with capacity in the school nursing system meaning that school nurses are not able to devote the appropriate amount of time to cases that really need their input. We have therefore carried out a full case audit to determine whether the existing approach to safeguarding and child protection within the service could be improved. This audit has revealed a number of areas where the multiagency safeguarding system could be improved in order to reduce significantly the bureaucratic burden on school nursing, without increasing the risk to other children. This would clearly free up school nurse time to focus on other issues, including giving adequate time to individual cases where their input is most appropriate.”

Source location
2014-0309-Response-by-Cumbria-County-Council
Page 2 · response
Published 3 July 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with Cumbria Partnership Foundation Trust to make necessary changes within the School Nursing Service under the existing contract.

Verbatim wording from the response
“We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015.”

Source location
2014-0309-Response-by-Cumbria-County-Council
Page 2 · response
Published 3 July 2014
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Build necessary School Nursing Service changes into the specification for commissioning from October 2015.

Verbatim wording from the response
“We are working with the Local Safeguarding Children Board to amend the multiagency systems appropriately, and with Cumbria Partnership Foundation Trust to make the necessary changes within the School Nursing Service on a voluntary basis within the context of the existing contract. We will be building all necessary changes into the new service specification to be commissioned from October 2015.”

Source location
2014-0309-Response-by-Cumbria-County-Council
Page 2 · response
Published 3 July 2014
Open published response
16 Apr2014
Bedfordshire and Luton
Concerns raised1
1. Lack of sufficient staffing for patient caseloads
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
  Increase the number of nurses allocated to ward 22 at night following the staffing establishment review.
  Stated by The TrustStated completed
2. Action
  Raise insufficient staffing and early escalation with ward staff through daily safety brief discussions.
  Stated by The TrustStated completed
3. Action
  Review clinical support available at night across the Trust.
  Stated by The TrustStated completed
1. Action
  Develop a revised hospital-at-night model to provide a robust 24/7 service.
  Stated by The TrustStated in progress
Respondent positions 1
1. Position
  Existing staffing reviews, risk assessments and on-call arrangements are considered sufficient to ensure adequate medical and nursing staffing.
  Stated by The TrustExisting arrangements considered sufficient
AI-generated summary

Sari Marlene KEEN · 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

Sari Marlene KEEN underwent surgery to remove colon tumours on 23 October 2013, developed a faecal anastomotic leak causing peritonitis and shock, and died following cardiac arrest on 24 October 2013. The substantive concerns were insufficient staffing and failures to recognise deterioration, escalate care, and call the Hospital Crash Team when her blood pressure became unrecordable.

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 staffing for patient caseloads
Wider context from the report
“(1) The first matter of concern was that three witnesses who gave evidence, two Senior Nurses and one Doctor, told me that on the night that Sara died there were insufficient members of staff available to deal with the caseload of patients and this was not unusual. They felt overwhelmed and yet unable to escalate the care. ”
Source location
Sari Marlene KEEN · 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 number of nurses allocated to ward 22 at night following the staffing establishment review.

Verbatim wording from the response
“Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

Source location
2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 16 April 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
Raise insufficient staffing and early escalation with ward staff through daily safety brief discussions.

Verbatim wording from the response
“The following actions have been undertaken to minimise the risk of this happening again:”

Source location
2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 2 · response
Published 16 April 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
Review clinical support available at night across the Trust.

Verbatim wording from the response
“• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

Source location
2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 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
Develop a revised hospital-at-night model to provide a robust 24/7 service.

Verbatim wording from the response
“• The Trust has also undertaken a review of the clinical support available at night across the Trust. Further work is underway to develop a revised ‘hospital at night’ model to meet the national strategy requirement of a robust 24/7 service.”

Source location
2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 3 · response
Published 16 April 2014
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing staffing reviews, risk assessments and on-call arrangements are considered sufficient to ensure adequate medical and nursing staffing.

Verbatim wording from the response
“Nursing Staff establishments are reviewed every six months using a number of different approaches. This includes using the expert opinions of the Chief Nurse, dedicated specialty matron and ward manager who have greater insight into the local clinical need and context of each ward setting. The establishments are also reviewed in the context of the wider quality performance of the ward which includes key nursing quality indicators, patient experience scores and workforce indicators such as sickness and turnover rates. In fact following our most recent establishment review the actual numbers of nurses on ward 22 at night has been increased.”

Source location
2014-0180-Response-by-Luton-Dunstable-University-Hospital
Page 1 · response
Published 16 April 2014
Open published response
8 Apr2014
Manchester South
Concerns raised1
1. Insufficient nursing and medical staffing capacity for ward demands
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.

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

Frederick William Hall · 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

Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.

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 for ward demands
Wider context from the report
“7. Whilst 'on paper' the staffing levels were adequate, in fact due to the specific demands on the wards during that period, there was a need for more nursing /medical staff to be available. What measures are in place to address this type of situation? ”
Source location
Frederick William Hall · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Mar2014
Mid Kent and Medway
Concerns raised1
1. Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments
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

Lorna Frances Cullen · 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

Lorna Frances Cullen died after falling from the upper level of a multi-storey car park on 23 December 2012, following attendance at an emergency department where she left before receiving a mental health assessment. The principal concern was the long-term adequacy of liaison psychiatry nurse staffing in hospital emergency departments, as patients requiring assessment were regularly waiting well beyond the standard two-hour period.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments
Wider context from the report
“It became apparent that if the deceased had waited at the hospital she would not in fact have been seen until at least midnight and possibly later (more than twice the standard time). The reason for this was due to the fact that there was only one nurse on duty during the ‘late’ shift and in view of the fact that a mental health assessment takes between 2-3 hours the demand (the nurse on duty receives referrals from a number of different departments within the hospital) far exceeded the available staffing provision. It was apparent from the evidence of at least three witnesses that at the time of this death in 2012, patients in need of mental health assessment by the on-duty liaison psychiatry nurse were regularly waiting well in excess of 2 hours. The importance of a mental health assessment taking place as soon as possible after such a need has been identified is obvious. A specially trained psychiatry nurse is more likely to pick up on the more subtle indicators as to risk, that means it is more likely that appropriate management of that risk can be put into place thus affording the most effective preventative measures against self-harm and harm to others. During the course of the inquest I heard evidence that as a result of review additional resources had been awarded to facilitate increased staffing levels and to provide a 24 hour service (previously there were no liaison nurses on duty after midnight) thus providing continuation of services before and after midnight. I was advised that the additional levels of funding remain in place until at least the end of September 2014. The effect of these resources has been to significantly decrease the number of patients who require mental health assessments and who have to wait in excess of 2 hours. It has meant that staff can properly research a patient’s history prior to or as part of the assessment which is not only essential so far as assessing the individual patient but is useful in assessing priority as between patients waiting to be seen. The matter of concern therefore relates to the long term (ie post September 2014) liaison psychiatry nurse staffing levels covering hospital emergency departments. ”
Source location
Lorna Frances Cullen · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Mar2014
London (West)
Concerns raised1
1. Inadequate staffing numbers and inappropriate staff skill mix
This report raised 5 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 5
1. Action
  Conduct an unannounced joint compliance inspection of The Priory Hospital Roehampton and require remedial action for identified non-compliance.
  Stated by Care Quality CommissionStated completed
2. Action
  Conduct a joint unannounced inspection assessing medicines management and staffing compliance actions.
  Stated by Care Quality CommissionStated completed
3. Action
  Incorporate ward staffing levels and skill mix into ongoing provider monitoring and the next inspection.
  Stated by Care Quality CommissionStated planned
1. Action
  Separate Garden Wing into two wards with dedicated managers, nursing teams, therapists and activity coordinators.
  Stated by Priory GroupStated completed
2. Action
  Continue monitoring ward staffing levels and skill mixes to ensure they remain appropriate.
  Stated by Priory GroupStated in progress
Respondent positions 1
1. Position
  The two wards are sufficiently staffed and skilled, with separate management and ongoing monitoring of staffing levels and skill mix.
  Stated by Priory GroupExisting arrangements considered sufficient
AI-generated summary

Neil James Carter · 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 James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate staffing numbers and inappropriate staff skill mix
Wider context from the report
“(2) I heard evidence that indicated an enduring situation where the ward frequently had inadequate numbers of staff with an inappropriate skill mix and with an inappropriate layout over two floors. There was a lack of discipline with staff failing to accept a nurse in charge’s authority authority. Management was informed of some issues but failed to listen or act. ”
Source location
Neil James Carter · 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 an unannounced joint compliance inspection of The Priory Hospital Roehampton and require remedial action for identified non-compliance.

Verbatim wording from the response
“Since June 2013 the Commission have carried out the following compliance inspections of The Priory Hospital Roehampton:”

Source location
2014-0103-Response-by-Care-Quality-Commission
Page 4 · response
Published 5 March 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
Conduct a joint unannounced inspection assessing medicines management and staffing compliance actions.

Verbatim wording from the response
“3. 12 March 2014: The Commission carried out a joint unannounced inspection comprising a compliance inspector, a Mental Health Act Commissioner and a pharmacy inspector. The inspection focused on assessment against outcomes 9 and 13 to consider whether the compliance actions that were required following the inspections on 25 June and 3 July 2013 had been satisfactorily completed. We summarise the findings below:”

Source location
2014-0103-Response-by-Care-Quality-Commission
Page 6 · response
Published 5 March 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
Incorporate ward staffing levels and skill mix into ongoing provider monitoring and the next inspection.

Verbatim wording from the response
“• A Mental Health Act Commissioner made a further visit to the ward, where Mr Carter was a patient, on 19 March 2014. They found safe staffing levels were in place on that occasion. However, the Commission intends that ward staffing levels and, in particular, the skill-mix of staff be incorporated within our monitoring of the provider, as well as in the planning and focus of our next inspection of The Priory Hospital Roehampton.”

Source location
2014-0103-Response-by-Care-Quality-Commission
Page 8 · response
Published 5 March 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
Separate Garden Wing into two wards with dedicated managers, nursing teams, therapists and activity coordinators.

Verbatim wording from the response
“I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.”

Source location
2014-0103-Response-by-Priory-Group
Page 2 · response
Published 5 March 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
Continue monitoring ward staffing levels and skill mixes to ensure they remain appropriate.

Verbatim wording from the response
“I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.”

Source location
2014-0103-Response-by-Priory-Group
Page 2 · response
Published 5 March 2014
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The two wards are sufficiently staffed and skilled, with separate management and ongoing monitoring of staffing levels and skill mix.

Verbatim wording from the response
“I am informed that following Mr Carter's death, Garden Wing was separated into two distinct wards. Each ward has its own ward manager and nursing team together with therapists and activity co-ordinators. I am informed by the hospital that the two smaller wards are sufficiently staffed and that the managers and nursing staff of the wards are sufficiently skilled and experienced. The wards are supervised by the Roehampton Hospital Director and additional clinical support is provided by the Clinical Services Manager. They will continue to monitor staffing levels and skill mixes to ensure they are appropriate.”

Source location
2014-0103-Response-by-Priory-Group
Page 2 · response
Published 5 March 2014
Open published response
17 Jan2014
North London
Concerns raised1
1. Unavailability of specially trained nursing staff for hospital patients with substance misuse
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.
Respondent positions 3
1. Position
  Routine specialist substance-misuse nurses are unnecessary because registered nurses, multidisciplinary teams and established care pathways provide appropriate care.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  Local commissioners are responsible for determining specialist substance-misuse nurse provision according to assessed local need and resources.
  Stated by Department of Health and Social CareRedirects responsibility
2. Position
  The presence of a specialist substance-misuse nurse would not have produced a different outcome in this case.
  Stated by Department of Health and Social CareDisputes the concern
AI-generated summary

Wayne Spencer Malcolm Broad · 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

Wayne Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance misuse.

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
Unavailability of specially trained nursing staff for hospital patients with substance misuse
Wider context from the report
“(3) Specially trained nursing staff should be available at hospitals for dealing with patients with substance misuse. ”
Source location
Wayne Spencer Malcolm Broad · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
Routine specialist substance-misuse nurses are unnecessary because registered nurses, multidisciplinary teams and established care pathways provide appropriate care.

Verbatim wording from the response
“You suggest in your third point that specially trained nursing staff should be available in hospitals for dealing with patients with substance misuse. I do not however consider that such specialist nurses should routinely be available in all hospitals.”

Source location
2014-0020-Response
Page 2 · response
Published 17 January 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
Local commissioners are responsible for determining specialist substance-misuse nurse provision according to assessed local need and resources.

Verbatim wording from the response
“However, the provision of specialist substance misuse nurses is a matter for local commissioners to determine based on an assessment of local needs. There may be some hospitals where the resources required to make this facility available would be justified but, where there are very few presentations from patients with substance misuse problems, providing such a service might not be the most effective use of available resources.”

Source location
2014-0020-Response
Page 2 · response
Published 17 January 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
The presence of a specialist substance-misuse nurse would not have produced a different outcome in this case.

Verbatim wording from the response
“In this case the patient was admitted with a life threatening condition needing emergency intervention. The effect of long term alcohol abuse and associated complications led to the need for emergency resuscitation. The role of a specialist substance misuse nurse would in contrast involve making an assessment of the patient and determining the best options in terms of referral or appropriate care pathway. In this case I do not feel that the presence of a specialist substance misuse nurse would have led to a different outcome for Mr Broad.”

Source location
2014-0020-Response
Page 3 · response
Published 17 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to provide Acute Liaison Nurse cover during staff absence

Insufficient Acute Liaison Nurse staffing capacity

Concerns raised1

Insufficient provision of nursing staff when patient circumstances require greater staffing levels

Concerns raised1

Insufficient continuous nursing cover on the ward

Concerns raised1

Insufficient nursing staffing capacity

Concerns raised1

Unrealistic school nurse service workload expectations

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

Lack of sufficient staffing for patient caseloads

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 nursing and medical staffing capacity for ward demands

Concerns raised1

Inadequate long-term liaison psychiatry nurse staffing levels covering hospital emergency departments

Concerns raised1

Inadequate staffing numbers and inappropriate staff skill mix

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.5

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 4

Actions described in response 4

Respondent positions 1

Actions described in response 5

Respondent positions 1