Recurring concern

Failure to prioritise clinical care over administrative work

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First reported 24 Nov 2016•Latest report 2 May 2025

Definition

What this concern includes

Includes failures in care or practice processes where clinical care needs are misclassified, deprioritised or delayed in favour of administrative tasks, including inadequate staff preparation to prioritise care and failure to distinguish requests requiring clinical assessment from true administrative work.

Not included

Excludes generic workload, staffing or administrative-capacity concerns where clinical care is not wrongly deprioritised or misclassified.
Excludes ordinary administrative delays that do not cause or threaten delayed clinical assessment or care.
Excludes failures in communication, supervision or documentation where prioritisation of clinical care over administrative work is not the shared unsafe condition.
Excludes condition-specific clinical pathways and named referral or triage systems when they provide a more specific supported boundary.

Reports: 2
Individual concerns: 2
Date range: 2016–2025
Stated actions: 3

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 Birmingham and Solihull Integrated Care Board1

Richmond Medical Centre (Solihull)1

The Children's Trust1

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.

2 May2025
Inner West London
Concerns raised1
1. Insufficient staff training on prioritising care over administrative tasks
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 2
1. Action
  Allocate a dedicated administrator to each house so care staff can focus on caregiving.
  Stated by The Children's TrustStated completed
2. Action
  Clarify staff roles and formally prioritise direct care over administrative duties.
  Stated by The Children's TrustStated completed
AI-generated summary

Raihana Oluwamidalo Awolaja · 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

Raihana Oluwamidalo Awolaja, who was tracheostomy-dependent and required one-to-one nursing care, was left unsupervised at her residential care home for approximately fifteen minutes. Secretions blocked her tracheostomy, causing respiratory compromise and cardiac arrest; she was later resuscitated but died of hypoxic ischaemic brain injury. The principal concerns included inadequate supervision and staffing, possible shortcomings in training and communication, and concerns about the care provider’s investigation and handling of concerns raised by next of kin.

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 staff training on prioritising care over administrative tasks
Wider context from the report
“5. That there may be training issues in relation to the prioritisation of administrative tasks above care. ”
Source location
Raihana Oluwamidalo Awolaja · Prevention of Future Deaths report
Page 4 · 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
Allocate a dedicated administrator to each house so care staff can focus on caregiving.

Verbatim wording from the response
“• Dedicated Administrative Support: Each house has been allocated a dedicated administrator, allowing care staff to focus on their primary caregiving responsibilities without being unduly distracted by administrative tasks.”

Source location
Response from The Children’s Trust
Page 1 · response
Published 19 May 2025
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
Clarify staff roles and formally prioritise direct care over administrative duties.

Verbatim wording from the response
“• Role Clarity: We have clarified staff roles to ensure that direct care is prioritised over administrative duties. Staff have been formally instructed on this expectation.”

Source location
Response from The Children’s Trust
Page 1 · response
Published 19 May 2025
Open published response
24 Nov2016
Birmingham and Solihull
Concerns raised1
1. Failure to distinguish clinical assessment tasks from true administration tasks
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 1
1. Action
  Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.
  Stated by NHS Solihull Clinical Commissioning GroupStated planned
AI-generated summary

Timothy Simon Jones · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

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 distinguish clinical assessment tasks from true administration tasks
Wider context from the report
“2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”
Source location
Timothy Simon Jones · 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
Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.

Verbatim wording from the response
“• In addition a ‘learning alert’ will be issued to all Solihull member practices to highlight concerns and learning in relation to: ○ Recording of requests for home visits ○ GP home visit policies ○ Nursing/residential home requests for GP home visits ○ Classifications of administrative tasks”

Source location
2016-0421-Response-by-Solihull-Clinical-Commissioning-Group
Page 1 · response
Published 19 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient staff training on prioritising care over administrative tasks

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

Concerns raised1

Failure to distinguish clinical assessment tasks from true administration tasks

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

Actions described in response 2

Actions described in response 1