Recurring concern

Insufficient qualified healthcare staffing capacity

First to latest report 30 Jul 2013 — 1 Jun 2026

Reports that mention this concern
85
Times this concern has been raised
89
Stated actions linked to this concern
154

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.

What is 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 and published responses 85 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Barbara White · 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

    Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

    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 and unfamiliar nursing staff on the Surgical Unit

    Wider context from the report

    “3. There was a shortage of staff on duty on the Surgical Unit on the night of the 9th December. There was only one auxiliary nurse who was not familiar with the Surgical Unit. This Unit is one step down from the High Dependency Unit and the patients require a high level of nursing care. However, there was a lack of escalation of this issue to the Night Nurse Practitioner. ”

    Source location

    Barbara White · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester West

    AI-generated summary

    Howard Simon Sankey · 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

    Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff training.

    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 the large and unpredictable referral volume

    Wider context from the report

    “(1) During the Inquest evidence was heard that :- i) The categorisation and allocation as between Emergency, Urgent and Routine referrals is done by an Administration Assistant who is not qualified nor trained to carry out such duties. The Administration Assistant enters the service user on to the OTTER system with the category of urgency and the hard copy file is delivered to the Senior Nurse Practitioner including details of the referral which should be acknowledged by the Senior Nurse Practitioner within 30 minutes of receipt. ii) There is no review of the hard copy file, the referral form or the entry on the electronic patient record to enable a review of the category of urgency assessed by the Administration Assistant. Furthermore there is no action taken by the Senior Nurse Practitioner to prioritise referrals within each category to identify the more urgent cases within each category to ensure contact with the service user within the most appropriate time for that service user. iii) The OTTER system provides a list of all referrals in date and time order identifying the category of urgency but the list is not available to each Senior Nurse Practitioner and the list is only available to the Manager of the team. iv) At the time of the referral relating to the deceased only one Senior Nurse Practitioner was on duty at any one time dealing with all referrals. The Gateway Team has 16 members who are engaged in different duties and many of the duties are out of the office. The Senior Nurse Practitioner on duty deals with all written or faxed referrals, including Emergency, Urgent and Routine referrals together with all telephone referrals and other request to Gateway either by telephone or by personal attendance. There are 500 to 600 recorded referrals to Gateway each month so that there are 25 to 30 referrals each working day. Evidence was given at the Inquest that a new team has been established at the Hospital to deal with referrals through the Accident and Emergency Department at the Hospital and an additional member of staff now works with the Senior Nurse Practitioner in relation to other referrals but there is still a very high and unpredictable workload for the Senior Nurse Practitioner each day. v) When a service user is not contacted or when an attempt to contact has failed the hard copy file is put into a file tray to be picked up whenever by another Senior Nurse Practitioner. There is no system of reviewing the none contact referrals within an appropriate and reasonable time. There is a handover from one Senior Nurse Practitioner to another Senior Nurse Practitioner at the end of each shift and there is a meeting each morning to discuss outstanding cases but there is no system to ensure that all outstanding cases are considered at the morning meeting and there is no re-prioritisation of the cases to ensure that all service users are contacted within an appropriate and reasonable period. In the case of the deceased his referral was not discussed at the morning meeting on the 3rd July 2013 after contact had failed at 19.36 hours the previous evening and his referral had not been reviewed by any Practitioner prior to his telephone call at 16.00 hours on the 3rd July 2013. vi) The evidence at the Inquest revealed ineffective management of the Team to co-ordinate and allocate resources to deal with an unpredictable number of referrals each day. The list of referrals in date and time order prepared by the computer system is only accessible to the Team Manager who did not appear to share the information on the list with Senior Nurse Practitioners to ensure that any delays in contact with a service user would be actioned and reviewed taking account of the date and time of the referral. 2. I have concerns with regard to the 5 Boroughs Partnership NHS Foundation Trust, particularly the Gateway Team, in relation to: i) The categorisation and allocation of referrals by an Administration Assistant who has insufficient knowledge and who is not trained to make such important decisions ii) The prioritisation of each referral to ensure contact within an appropriate and reasonable period of time having regard to the urgency and merits of each referral. iii) The system to ensure contact with service users within appropriate time periods particularly when the initial contact with the service user has failed. iv) The systems and procedures to ensure contact with service users within appropriate time periods following receipt of the referral and the fact that the computerised list of referrals in date and time order is not available to Senior Nurse Practitioners. v) The ineffectiveness of handovers as between Senior Nurse Practitioners and the ineffectiveness of the morning meetings to review referrals particularly those referrals where the initial contact with the service user has failed. vi) The staffing levels on each shift, particularly having regard to a large and unpredictable volume of referrals each day. vii) The ineffective management of the team as a whole and in particular Senior Nurse Practitioners to co-ordinate and allocate resources to deal with the large volume of referrals within the appropriate time period. viii) The training of staff in relation to the written Operational Guidance, which was not followed by any of the Senior Nurse Practitioners who gave evidence at the Inquest, to ensure that referrals are dealt with and service users are seen within appropriate time periods. ”

    Source location

    Howard Simon Sankey · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish full assessment-team staffing, recruit all vacancies and provide rota coverage across the 24-hour period.

    Verbatim wording from the response

    “IV. The work of the assessment team can be unpredictable due to the unplanned nature of referrals. I can confirm that whilst at the time of the incident, the team had gaps in staffing due to sickness and vacancies; the team is now fully established. Sickness continues to be proactively managed at a local level and monitored across the entire business stream in line with Trust policy. Staff work to a rota that ensures maximum coverage across the 24 hour period.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 2 · response
    Published 27 December 2013

    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

    Undertake an Acute Care Pathway review covering staffing, skill mix and pathway effectiveness across teams.

    Verbatim wording from the response

    “VII. The Trust are currently undertaking a review of the entire Acute Care Pathway (ACP) which includes a review of staffing levels and skill mix across all teams and the effectiveness of pathways between services. This is due to be reported at the end of February 2014. The team manager receives regular management supervision where the concerns you have raised have been discussed and action taken.”

    Source location

    2013-0361-Response-by-5-Boroughs-Partnership
    Page 3 · response
    Published 27 December 2013

    Open published response

  3. Manchester South

    AI-generated summary

    William Joseph Wilkinson · 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

    William Joseph Wilkinson slipped on the pavement while shopping on or about 9 December 2012, fractured his ankle, was admitted to hospital, and later died after complications. Concerns included the availability of ordered one-to-one nursing, difficulties logging onto the hospital computer system, an incomplete Fluid Balance Chart, and the lack of direct orthopaedic input in the Emergency Department.

    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 required one-to-one nursing

    Wider context from the report

    “(1) I was told that despite one-to-one nursing being required for Mr Wilkinson and indeed being ordered, this is not always available. There was clear evidence that had such nursing standards been available Mr Wilkinson may not have developed the problems which led to his death. ”

    Source location

    William Joseph Wilkinson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    Mohammed Mozammel Hussain CHAUDHURY · 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

    Mohammed Chaudhury suffered multiple injuries in a traffic collision and later developed five severe, septic pressure sores while in hospital. The report raised concerns about inadequate turning, incomplete care planning and tissue-viability referrals, inconsistent risk scoring, shortages in nursing staff, and uncertainty about whether staffing levels for unconscious patients requiring regular turning were safe.

    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

    “(3) Nursing rotas for the period were not available. Some days were reported as below establishment. (8 by day and 6 by night for 31 patients of which at least a ¼ were high dependency). Not all bank shifts were filled. ”

    Source location

    Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. West Sussex

    AI-generated summary

    Phillip Arthur Pratt · 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

    Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

    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 additional nursing staff for high-risk patient monitoring

    Wider context from the report

    “During the course of the inquest, ████████, Head of Nursing for St Richards Hospital, gave evidence in relation to a “Root Cause Analysis Investigation Report”. The stated purpose of the report was “To identify the root causes and key learning from an incident and use this information”. The report covered a number of areas of concern arising from the investigation. ████████ gave evidence to say that a number of practices and additional training have already been put in place to address some of the issues set out in the report. The matters of concern that I raise herein deal with issues raised in the report in respect of which standard action has not yet been taken. (1) On admission to hospital and at pre-assessment stage, there was a note of the patient’s medication but no note as to dosage of medication. The Report indicates no attempts were made to contact the patient’s GP or family to ascertain precise levels of medication; (2) As it was not expected the patient would remain in hospital for a protracted stay, the need for alcohol detoxification was not considered at an early stage and not reassessed when the reason for the patient’s admission changed; (3) The onset of agitation and confusion had been recognized, with a (4) There was a delay in discontinuing the prescription for Tramadol despite the onset of confusion which is one of the contra-indications of that medication; (5) There was a delay in x-raying the shoulder. The report comments (6) Requests were made for nurse special staff to monitor a high risk patient but extra staff were not available. ”

    Source location

    Phillip Arthur Pratt · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026