Recurring concern

Failure to ensure adequate senior nursing leadership for safe patient care

First to latest report 1 Sep 2014 — 4 Apr 2024

Reports that mention this concern: 7
Times this concern has been raised: 7
Stated actions linked to this concern: 11

What this concern includes

Includes failures in arrangements for providing, selecting, authorising or supporting senior nurses who lead nursing shifts or direct nursing care, including insufficient senior nursing leadership capacity, inadequate empowerment to escalate concerns and unreliable procedures for determining which nurse clinicians are appropriate to lead.

What is not included

Excludes generic nursing staffing shortages where the report does not identify an effect on senior nursing leadership or nursing-shift leadership.
Excludes generic clinical leadership, medical leadership or organisational governance deficiencies that do not concern senior nursing leadership of patient care.
Excludes failures of frontline nurse competence, communication, documentation or escalation where senior nursing leadership capacity or assurance is not the shared unsafe condition.
Excludes general staff empowerment or workplace-culture concerns without a direct connection to senior nursing leadership and safe patient-care oversight.

Trends

Reports over time

Reports mentioning this concern, 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.

Care Quality Commission1

Greater Manchester Mental Health NHS Foundation Trust1

Hc-One Limited1

Lancashire Teaching Hospitals NHS Foundation Trust1

Manchester University NHS Foundation Trust1

NHS England1

NHS Greater Manchester Integrated Care Board1

NHS Surrey and Sussex Integrated Care Board1

Royal Free London NHS Foundation Trust1

Sherwood Forest Hospitals NHS Foundation Trust1

Sussex Partnership NHS Foundation Trust1

Reports and published responses 7 reports

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

4 Apr2024
Nottinghamshire
Concerns raised1
1. Insufficient paediatric nursing capacity and senior nurse support in the Emergency Department
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sherwood Forest Hospitals NHS Foundation Trust
Stated actions 9
1. Sherwood Forest Hospitals NHS Foundation Trust
  Roster registered children’s nurses during identified peak emergency-department attendance periods.
2. Sherwood Forest Hospitals NHS Foundation Trust
  Require adult nurses caring for children to complete specified paediatric experience, training, study days, e-learning and supervised shadowing.
3. Sherwood Forest Hospitals NHS Foundation Trust
  Record paediatric nursing staffing as a significant risk and review it monthly through specialty and Trust risk committees.
1. Sherwood Forest Hospitals NHS Foundation Trust
  Develop a rotational pathway for registered children’s nurses through continuous Emergency Department and paediatric collaboration.
2. Sherwood Forest Hospitals NHS Foundation Trust
  Train an Emergency Department adult nurse as a paediatric nurse, increasing staffing by one whole-time equivalent.
3. Sherwood Forest Hospitals NHS Foundation Trust
  Provide newly qualified registered children’s nurses with discipline-specific preceptors, supernumerary practice and Emergency Department induction.
4. Sherwood Forest Hospitals NHS Foundation Trust
  Review Emergency Department escalation processes for proactively identifying and escalating nursing staffing concerns.
5. Sherwood Forest Hospitals NHS Foundation Trust
  Add a peak-time Band 5 registered-nurse shift and improve Healthroster displays to identify children’s-area registered children’s nurse cover gaps.
6. Sherwood Forest Hospitals NHS Foundation Trust
  Implement a supervisory Band 7 Nurse in Charge role providing visible senior nursing support across the Emergency Department, with supernumerary deployment from July 2024.
Respondent positions 1
1. Sherwood Forest Hospitals NHS Foundation Trust
  Recruitment challenges mean the Trust is unable to meet RCPCH paediatric nursing workforce standards despite active recruitment.
  Unable to act
AI-generated summary

Tommy Jay Gillman · 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

Tommy Jay Gillman died on 8 December 2022 at Leicester Royal Infirmary after Salmonella Brandenberg meningitis caused sepsis and multi-organ failure. The report identified missed opportunities at Kings Mill Hospital, including delays in triage, escalation, monitoring, intravenous fluids and antibiotics. Concerns included insufficient paediatric nursing cover, undocumented handovers and an inadequate system for recognising and escalating the care of seriously ill babies.

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 paediatric nursing capacity and senior nurse support in the Emergency Department
Wider context from the report
“1. At times of high pressure and business, the Paediatric nursing complement is insufficient in the Emergency Department. There are inexperienced Paediatric nurses trying to manage a very high workload, without senior nurse support to try and increase staffing levels on a shift. The Facing the Future (RCPCH) standards for levels of Paediatric nursing are not met ”
Source location
Tommy Jay Gillman · 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
Roster registered children’s nurses during identified peak emergency-department attendance periods.

Verbatim wording from the response
“• A profile of when children and young people attend the ED over a 1-year period has been obtained to ensure that RNC’s are rostered on at peak times.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 1 · response
Published 15 April 2024
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
Require adult nurses caring for children to complete specified paediatric experience, training, study days, e-learning and supervised shadowing.

Verbatim wording from the response
“• A minimum set of core competencies that adult nurses must have completed prior to caring for a child or young person has been agreed as follows:”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 1 · response
Published 15 April 2024
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
Record paediatric nursing staffing as a significant risk and review it monthly through specialty and Trust risk committees.

Verbatim wording from the response
“• RNC staffing within the ED is recorded on the Trust risk register as a significant risk and is reviewed monthly by the speciality and Trust Risk Committee. This has led to the development of the rotational post (see below).”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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 rotational pathway for registered children’s nurses through continuous Emergency Department and paediatric collaboration.

Verbatim wording from the response
“• Continuous collaborative working between ED and the division of Women and Children to develop a rotation pathway for RNC’s is planned to be in place from October 2024.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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
Train an Emergency Department adult nurse as a paediatric nurse, increasing staffing by one whole-time equivalent.

Verbatim wording from the response
“• ED Adult Nurse released to complete Paediatric Nurse Training (18 months) due to complete in September 2024. This will increase staffing by 1 WTE.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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 newly qualified registered children’s nurses with discipline-specific preceptors, supernumerary practice and Emergency Department induction.

Verbatim wording from the response
“Sherwood Forest Hospital provide all newly qualified RNCs with a nominated preceptor, qualified in the same discipline of nursing with at least 12 months experience. All registered nurses within the preceptorship programme undertakes a minimum period of 4 weeks supernumerary practice which includes a Trust Orientation Day and Nursing and Midwifery Induction Programme. During this supernumerary period the RNC preceptee is provided with a local induction pertinent to the ED with a particular focus on children and young people. A preceptor will integrate Trust standards, competencies, objectives and Trust CARE values into practice and contribute to an environment which facilitates learning for the Preceptee to ensure they have appropriate skills to competently undertake their role.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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 Emergency Department escalation processes for proactively identifying and escalating nursing staffing concerns.

Verbatim wording from the response
“The ED senior leadership team have reviewed the escalation processes in place for proactively reviewing and escalating nursing staffing concerns.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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
Add a peak-time Band 5 registered-nurse shift and improve Healthroster displays to identify children’s-area registered children’s nurse cover gaps.

Verbatim wording from the response
“Healthroster, a system for producing rosters which take into account an employee’s skills is used to proactively to maximise the likelihood that each department has the appropriate number of staff whilst ensuring there is a safe skill mix. The ED children’s area rota is produced by the Band 7 lead nurse a minimum of 6 weeks in advance. An additional Band 5 RN shift has been added to the roster from 4pm-2am to support attendances at peak times. Following the Inquest improvements have been made locally to the Healthroster system to highlight specific nursing shifts for the children’s area. This change enables clearer identification of where there are gaps in RNC cover thus enabling the ED leads to ensure adult nurses with the minimum paediatric competencies are on duty.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a supervisory Band 7 Nurse in Charge role providing visible senior nursing support across the Emergency Department, with supernumerary deployment from July 2024.

Verbatim wording from the response
“It is not possible to predict sickness and short-term unplanned absence, therefore changes to staffing availability may need to be escalated and acted upon at short notice. At the time of Tommy’s attendance, the Band 7 leads were rostered on day shifts and included within the ED staffing figures. In April 2024, a new band 7 supervisory Nurse in Charge (NIC) role has been implemented within ED to ensure there is visible senior support available 24 hours a day for the entire department. At present, the NIC is included within staffing figures, however from July 2024 this role will be supernumerary.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 2 · response
Published 15 April 2024
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
Recruitment challenges mean the Trust is unable to meet RCPCH paediatric nursing workforce standards despite active recruitment.

Verbatim wording from the response
“The Royal College of Paediatrics and Child Health (RCPCH) Facing the Future: Standards for Children in Emergency Care Settings (2018) describe national standards for care applicable to children in Emergency Care settings. Recommendation 10 of these standards states that every Emergency Department (ED) must be staffed with two registered children’s nurses on each shift. However, the Care Quality Commission (CQC) and RCPCH recognise the challenges in recruiting Registered Children’s Nurses (RNC) and are working to support services through provision of guidance and an audit tool kit.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 1 · response
Published 15 April 2024
Open published response
17 Nov2022
Manchester North
Concerns raised1
1. Failure to ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Greater Manchester Mental Health NHS Foundation Trust
NHS England
Respondent positions 3
1. Greater Manchester Mental Health NHS Foundation Trust
  The Trust disputes that staff experience and skill mix were inadequate during the relevant weekend, stating no concerns had been identified.
  Disputes the concern
1. Greater Manchester Mental Health NHS Foundation Trust
  Existing staffing reviews, weekend briefings and escalation systems are considered sufficient to identify and address changing clinical and staffing needs.
  Existing arrangements considered sufficient
2. NHS England
  Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.
  Redirects responsibility
AI-generated summary

Rowan Louis Thompson · 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

Rowan Louis Thompson was a detained patient at the Gardner Unit who was found in his room on 3 October 2020, thought to be having a seizure, and died shortly after arriving at hospital. The investigation and inquest identified severe hypokalaemia, failures to communicate blood test results, missed and falsified observation records, inadequate emergency response arrangements, and concerns about staffing and auditing.

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 ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit
Wider context from the report
“3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit. ”
Source location
Rowan Louis Thompson · 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
The Trust disputes that staff experience and skill mix were inadequate during the relevant weekend, stating no concerns had been identified.

Verbatim wording from the response
“Staffing at the Gardener Unit – as is the case for all other wards within CAMHS – is continually monitored by local managers with review and approval processes in place at the time each staff rota is produced and proactively, and on a rolling basis, to ensure that each individual shift is fully staffed and takes into account any changes that may have occurred at ward level since the staff rotas were first prepared e.g. a change in observations. Briefing meetings occur in advance of every weekend to review staffing requirements for the full weekend and provide the opportunity for local managers to make any required changes.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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, weekend briefings and escalation systems are considered sufficient to identify and address changing clinical and staffing needs.

Verbatim wording from the response
“Staffing requirements for the Gardener Unit are determined both by the number of ward based nursing staff required to undertake planned tasks and duties during each shift (clinical care, administration of medication, liaison with other professionals and security/environmental requirements for example) and by the individual clinical and risk needs of the young people resident on the ward at that time. Staffing numbers and skill mix are therefore dynamic and can fluctuate on a shift-by-shift basis requiring close oversight of staffing to ensure that the needs of the young people are met safely, and that staff are supported to provide effective care.”

Source location
Response from Greater Manchester Mental Health NHS Foundation Trust
Page 2 · response
Published 18 October 2023
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
Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.

Verbatim wording from the response
“We understand you have also addressed this Report to Greater Manchester Mental Health NHS Foundation Trust. They will address specifics as to the changes being implemented on the ground.”

Source location
Response from NHS England
Page 1 · response
Published 18 October 2023
Open published response
10 Dec2019
Brighton and Hove
Concerns raised1
1. Lack of ward management and matron leadership
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Bethany Tengquist · 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

Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

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 ward management and matron leadership
Wider context from the report
“5. Staffing levels. It was accepted by the Unit Co-ordinator, the Clinical Lead Nurse Manager and on behalf of the Trust, that on 29th December 2018 staffing levels on Caburn Ward had reached crisis point: there had been no Ward Manager and no Matron in post and available for a significant period of time, in conjunction with a 50% reduction of substantive staff. There was a reliance on bank and agency staff, and - unsurprisingly in my view - low staff morale. A number of members of staff in evidence emphasised that they had raised the issue of staffing and their concerns with managers and senior managers, to no avail. The obvious concern is that in the context of an acute female ward, such as Caburn, but equally applicable to the male acute ward, where the cohort of patients have such complex and challenging mental health issues, it is critically important that there is a consistency of staffing, management and leadership. The conclusion of the jury reflects and reinforces my concern that the extensive reliance on bank and agency staff undermines the safe operation of the acute wards at Mill View Hospital and, should the position persist, gives rise to the risk of future deaths. ”
Source location
Bethany Tengquist · Prevention of Future Deaths report
Page 5 · concerns
Open source report
11 Jul2019
Manchester West
Concerns raised1
1. Use of agency nurses as senior staff in charge of shifts
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Hc-One Limited
Stated actions 2
1. Hc-One Limited
  Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
2. Hc-One Limited
  Complete and distribute a strengthened agency-staff orientation booklet across the company.
AI-generated summary

Robert Charles Rostron · 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

Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Use of agency nurses as senior staff in charge of shifts
Wider context from the report
“I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time. ”
Source location
Robert Charles Rostron · 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
Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.

Verbatim wording from the response
“There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.”

Source location
2019-0237-Response-by-The-Kind-Care-Company
Page 1 · response
Published 13 September 2019
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 and distribute a strengthened agency-staff orientation booklet across the company.

Verbatim wording from the response
“There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.”

Source location
2019-0237-Response-by-The-Kind-Care-Company
Page 1 · response
Published 13 September 2019
Open published response
8 May2017
Manchester City
Concerns raised1
1. Insufficient senior nursing staff in leadership roles
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Name not published · 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

A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.

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 senior nursing staff in leadership roles
Wider context from the report
“6. Staffing levels, competence and seniority. The levels and competence of staff ( whether agency or Trust employees ) needed to deliver safe and appropriate care and with sufficient senior Nursing staff in leadership roles requires assessment and implementation. ”
Source location
Name not published · Prevention of Future Deaths report
Page 5 · concerns
Open source report
13 Apr2017
Preston and West Lancashire
Concerns raised1
1. Deficient procedures for determining which nurse clinicians may lead a nursing shift
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michael John NEWELL · 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

Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

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
Deficient procedures for determining which nurse clinicians may lead a nursing shift
Wider context from the report
“(5) the conduct of the Nurse in charge of the ward of making no notes after her presence at a peri-arrest, neither seeking or obtaining any direction from the medical team as to future management, not directing any further resuscitation in accordance with documented medical plans in the notes and lack of completion of the fluid balance chart would suggest that the Trust's procedures for determining which nurse clinicians may lead a nursing shift should be reviewed. ”
Source location
Michael John NEWELL · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Sep2014
Inner North London
Concerns raised1
1. Lack of clarity of ward leadership and support
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring 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
Lack of clarity of ward leadership and support
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

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Insufficient paediatric nursing capacity and senior nurse support in the Emergency Department

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

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

Concerns raised1

Failure to ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit

Linked responses

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of ward management and matron leadership

Concerns raised1

Use of agency nurses as senior staff in charge of shifts

Linked response

Stated actions 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

Insufficient senior nursing staff in leadership roles

Concerns raised1

Deficient procedures for determining which nurse clinicians may lead a nursing shift

Concerns raised1

Lack of clarity of ward leadership and support

Stated actions 9

Respondent positions 1

Respondent positions 3

Stated actions 2