Recurring concern

Failure to provide adequate supervision of care staff

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First reported 30 Aug 2013•Latest report 17 Oct 2024

Definition

What this concern includes

Includes failures of supervision, support or management specifically concerning care staff or carers responsible for delivering care, including inadequate oversight, supervision arrangements or escalation of unsafe practice.

Not included

  • Excludes generic staffing shortages, training or governance deficiencies unless they directly concern supervision or management of care staff.
  • Excludes supervision of clinicians, police call handlers, prisoners, residents or other non-care staff unless the assertion specifically concerns staff delivering care.
  • Excludes failures in the care delivered to a person where no deficiency in care-staff supervision or management is identified.
Reports
15

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2013–2024

First to latest report issue date

Stated actions
15

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission4
Department of Health and Social Care2
Alternative Futures Group Limited1
Bedfordshire Hospitals NHS Foundation Trust1
Corbett House Nursing Home1
Greater Manchester Mental Health NHS Foundation Trust1
gtd healthcare1
Herries Lodge1
Homedotcare Limited1
Islington Social Services1
Leeds Teaching Hospitals NHS Trust1
Litch Care Services Limited1
LNT Software1
Mersey Care NHS Foundation Trust1
Milton Keynes University Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Milton Keynes

    AI-generated summary

    Ethan Robert Johnson · 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

    Ethan Johnson was born following an urgent Caesarean section, with no respiratory effort or heart rate, and died after intensive care treatment was withdrawn. The concerns included a lack of effective leadership, support and escalation when an abnormal CTG was identified. The inquest concluded that delayed delivery resulted in a lost opportunity to deliver him earlier and provide further medical treatment.

    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 effective senior support for abnormal CTG monitoring

    Wider context from the report

    “(1)That the most junior member of staff (midwife) was left to look after ████████ even though the CTG trace was deemed abnormal. The midwife felt unsupported. ”

    Source location

    Ethan Robert Johnson · 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

    Strengthen newly qualified midwives’ preceptorship through supernumerary supported practice with experienced senior midwives.

    Verbatim wording from the response

    “In response to your concern, however, the new Head of Midwifery has strengthened the preceptorship period for newly qualified midwives. This means that they are supernumerary for several weeks and will be supported by experienced senior practice development midwives, whilst being familiarised in departmental processes.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 1 · response
    Published 29 September 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 two-hourly Band 7 coordinator rounding for patients receiving one-to-one care.

    Verbatim wording from the response

    “Furthermore, 2 hourly ‘intentional rounding’ of all patients undergoing 1:1 care (antenatal, labour, and postnatal) by a Band 7 Co-ordinator is now in place to ensure that appropriate care is being given through support of the patient’s individual midwife.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 1 · response
    Published 29 September 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

    Clarify staff responsibilities for patient reviews, senior-help escalation and upward-escalation timescales in writing.

    Verbatim wording from the response

    “On the ward the CTG did not require immediate intervention, so when the doctor had not attended within a reasonable timescale it was escalated appropriately. We have written to every member of staff clarifying their responsibilities if they are asked to review a patient, as well as what to do if senior help has been unable to attend. This includes timescales for upward escalation.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 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

    Introduce ‘fresh eyes/ears’ stickers to ensure hourly senior review of intermittent and continuous fetal monitoring.

    Verbatim wording from the response

    “‘Fresh eyes/ears’ stickers have been introduced to ensure hourly senior review of both intermittent and continuous fetal monitoring.”

    Source location

    2015-0393-Response-by-Milton-Keynes-University-Hospitals-NHS
    Page 2 · response
    Published 29 September 2015

    Open published response

  2. Bedfordshire and Luton

    AI-generated summary

    Willow Davies · 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

    Willow Davies was born at Bedford Hospital on 8 February 2014 and became pale and floppy shortly afterwards; CPR was commenced, and her death was confirmed later that morning. The substantive concerns related to the allocation and support of a newly qualified midwife who had no prior experience assisting with newborn resuscitation, the failure to account for midwives’ experience when allocating women, and the operation of the Supervisors of Midwives system.

    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 of the Supervisors of Midwives system to support pregnant women and midwives

    Wider context from the report

    “3. That system of ‘Supervisors of Midwives’, as it operates at Bedford Hospital, is in urgent need of review to ensure that it is working to support pregnant women and midwives in the Trust. ”

    Source location

    Willow Davies · 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 new starter midwives with a structured orientation period, nominated preceptor and managerial and supervisory support tailored to learning needs.

    Verbatim wording from the response

    “The Trust recognises that all new members of staff, whatever their experience, need a period of time to become familiar with local procedures and practices. Within the Maternity Unit at Bedford Hospital, an orientation period is allocated. ‘New starters’ unfamiliar with the Trust (including a newly qualified midwife) would undertake this programme for up to a month. Within this period, the new starter works with a nominated midwife for support and is expected to complete a bespoke orientation programme, developed following discussion”

    Source location

    2015-0157-Response-by-Bedford-Hospital-NHS-Trust
    Page 1 · response
    Published 21 April 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 pregnant women with information on accessing Supervisors of Midwives and maintain round-the-clock, year-round supervisory availability for women and staff.

    Verbatim wording from the response

    “A SoM Information Leaflet, based on the NMC leaflet “Support for Parents - How supervision and supervisors of midwives can help you “ (2009) is given to every pregnant woman when she registers her pregnancy through a process called ‘booking’. This leaflet sign-posts the family on how to access a Supervisor of Midwives and outlines the functions of statutory supervision. Bedford Hospital SoMs have an ‘on call’ rota, covering 24 hours availability, 365 days a year, and may be contacted by both users of the service and staff working both locally and regionally, for advice and support. The family in this tragic case had the involvement of a SoM during and after the completion of the investigation and prior to, during and since the Coroner’s Inquest Hearing.”

    Source location

    2015-0157-Response-by-Bedford-Hospital-NHS-Trust
    Page 3 · response
    Published 21 April 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

    The statutory Supervision of Midwives system complies with applicable standards and is considered effective in supporting mothers and midwives.

    Verbatim wording from the response

    “The statutory Supervision of Midwifery system in the Trust is modelled on the recommendations in the Local Supervising Authority Standards for Supervision (2009). An annual Supervision of Midwifery (SoM) Report is received by the Trust Board and Local Supervising Authority for Midwifery and this demonstrates full compliance.”

    Source location

    2015-0157-Response-by-Bedford-Hospital-NHS-Trust
    Page 3 · response
    Published 21 April 2015

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    Connor Adrian Turner · 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

    Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving hospital.

    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 initially supervise parents and carers performing oxygen-supply transfers until competent

    Wider context from the report

    “(1) There is no system in place for nursing staff to instruct and train parents and carers in the transfer of the oxygen supply from the main supply to a portable oxygen cylinder. (2) That parents and carers should be initially supervised in forming this task until they are deemed to be competent to do so. (3) That when a transfer has been made in preparation for the patient leaving the hospital, albeit temporarily, the patient should not be allowed to leave until an independent check has been made and all concerned are satisfied that the apparatus is functioning correctly and that those taking the patient out of hospital are competent to use the apparatus and that the appropriate reference to this should be made in the case notes. ”

    Source location

    Connor Adrian Turner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    CHRISTOPHER TOKE AJAYI · 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

    Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

    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

    Inconsistent supervision of Care Coordinators

    Wider context from the report

    “Mr Ajayi was aged 45 when he died. He had a long history of mental illness and a forensic history. He suffered with severe mental illness with a diagnosis of paranoid schizophrenia in 1989 which was amended to schizo-affective disorder in 2002. He was a wanderer and also not always compliant with medication. He was single and had little or no contact with his family in the time leading up to his death. In the last hospital admission before his death he was diagnosed with HONK – Hyperosmolar non-Ketotic coma. This means his blood sugar was high. He now required insulin to control his diabetes and he was, when discharged, to administer this to himself twice a day. On the 9th August 2012 there was a discharge planning meeting at the Maudsley (his last hospital admission). His Care Coordinator attended. It was known by then, because of his poor history of being non-compliant, that he would be being discharged with a Community Treatment Order in place. His named Care Coordinator does not seem to recall much about this meeting but has acknowledged that he would have been told that Mr Ajayi was now insulin dependent. From thereon, it appears that nothing of value was done in relation to Mr Ajayi's discharge planning. He was eventually discharged, wrongly, into unsupported accommodation with no care package, where no GP was caring for him and no Diabetic nurse aware of his discharge. Whilst his named Care Coordinator was on leave his colleague, another Care Coordinator, equally did not ensure everything was in place. Both argued that as Mr Ajayi was placed by Southwark Council, after discharge, into accommodation out of the borough, that militated, practically, in relation to them visiting post discharge. No one was to visit him. To use the words that Counsel for the family used, this group of staff (Care Coordinators) carry an enormous responsibility. The job must be carried out with great diligence and care. Staff must be of the right calibre, and have the right training, and support, to carry out their tasks well. The evidence revealed that these members of staff have a high degree of delegation imposed upon them. They are dealing with probably the most vulnerable people in society. It cannot be uncommon for a mentally unwell person to be discharged from hospital whilst suffering from a physical condition. One impinges on the other when that person is required to self-administer life-saving treatment to themselves. Therefore, they are particularly vulnerable. I acknowledge that patients such as Mr Ajayi, who frequently disengage with treatment, can only have their risk of harm/death reduced, not eliminated. However, this case highlighted so very many missed opportunities, mainly within the department of Care Coordinators. I have heard some evidence about resources impinging upon matters. Certainly, in this case, the accommodation which would be available for an individual such as Mr Ajayi (who was on the Sexual Offender's list as well as having the problems cited above), is, and was, limited. However, this report is not concerning that issue. It concerns the ability of this group of staff to carry out their jobs ensuring the lowest possible risk to their users as can be achieved. If necessary, Mr Ajayi should have (as would have been likely), stayed in hospital until the right discharge arrangement was in place (supported accommodation or unsupported with an intensive package of care). The caring element of the Care Coordinator role was missing. I am assured that the team that was responsible for Mr Ajayi's community care have developed a more structured multi-disciplinary approach including monitoring of 7 day follow up and I am told is robustly monitored in respect of compliance with the seven day follow up), and the identification of high risk patients such as Mr Ajayi. I am further assured that discharge planning is expected to be comprehensively and carefully planned before discharge. Sadly, I did not find this evidence reflected in the Care Coordinators' evidence. I have not been shown any audit figures to prove that changes have been checked as in action comprehensively, and the evidence was not impressive in relation to changes within this particular department. No re-training was evident. Both Care Coordinators were experienced and both also knew Mr Ajayi and his history, albeit not acting upon his new diagnosis. The evidence as a whole came across as still a service dealing with extremely vulnerable members of the public, where crucial decisions and follow up impinge directly on those individual's well-being, as well as others in the community. There appears to have been no root and branch overhaul of the department. Further, there was inconsistent evidence as to supervision, which in itself, would only account for supervisory control over some users of the service, at that particular time. I have concerns that the named Care Coordinator told me that his supervision was two weekly, where his manager told me it was monthly. Other than more supervision, I am struggling to find any other tangible changes that I am sure have been made, to prevent this group of staff from allowing the same circumstances to occur again. ”

    Source location

    CHRISTOPHER TOKE AJAYI · 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

    Revise, disseminate and publish the Trust supervision policy with clearer expectations for clinical and social-work staff.

    Verbatim wording from the response

    “• Trust revised Supervision policy (Sept 2014); this recent policy update which covers Trust and LBS staff, has been sent out to all staff and available on the Trust intranet for reference, sets out clear expectations of staff supervision, recognising effective supervision as an integral aspect of the working lives of all NHS clinical and social work staff to support them to deliver the best care to patients and their carers, provide opportunity to develop competent parishioners and to develop their skills.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 6 · response
    Published 31 October 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 capacity within community caseloads with primary-care and third-sector stakeholders to support lower care-coordinator caseloads.

    Verbatim wording from the response

    “• Case load management: Southwark community psychosis teams have active case-loads between 250-300 patients, resulting in average Care Co-ordinator case-loads of 25-30; the Trust continues to work with stakeholders in Primary care and the Third sector to develop capacity within the active case load, aiming ideally to reduce the average Care Co-ordinator case load to facilitate enhanced delivery of evidence based interventions; case loads are monitored on an ongoing basis, both within 1:1 supervision, and across the community as a whole.”

    Source location

    2014-0558-Response-by-South-London-and-Maudsley-NHS-Trust
    Page 6 · response
    Published 31 October 2014

    Open published response

  5. South Yorkshire (Western)

    AI-generated summary

    Mrs May Gibson · 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 May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

    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 supervision

    Wider context from the report

    “9) the evidence as a whole gave a picture of an establishment that had no cohesive management at the time, with staff who were caring but insufficiently trained and supervised. ”

    Source location

    Mrs May Gibson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026