Recurring concern

Inadequate contingency planning for safe patient care during staffing shortages

First to latest report 19 Jun 2018 — 4 Feb 2026

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
7

What this concern includes

Includes failures of contingency planning specifically intended to maintain safe patient care or clinical cover during staff shortages, staff absence or industrial action.

What is not included
  • Excludes ordinary staffing shortages or vacancies without a reported failure of contingency planning or safe response.
  • Excludes contingency planning for non-staffing hazards, such as equipment, security or lockdown risks.
  • Excludes generic service-capacity, bed-availability or workforce-resource deficiencies unless the report explicitly links them to inadequate contingency planning for safe patient care during staffing disruption.
  • Excludes individual failures to escalate, document or deliver care when they are not part of a staffing-disruption contingency plan.

Reports and published responses 6 reports

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

  1. South Wales Central

    AI-generated summary

    Joan Marilyn READ · 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

    Joan Marilyn Read, aged 91, died at the University Hospital of Wales on 18 March 2025 after a period of deterioration and decline. A severely deranged B12 result was not communicated or treated following her 2023 admission, and the report states that failure to address the deficiency more than minimally contributed to her death. The principal concern was the absence of year-round cross-cover for the single consultant responsible for geriatric perioperative care, creating a risk that urgent results could be missed during absences.

    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 establish year-round cross-cover within a doctor’s job plan

    Wider context from the report

    “(1) Evidence revealed that a single medical consultant is responsible for geriatric perioperative care (POPS). There is no cross-cover during periods of expected and unexpected absence. There is a risk that deranged test results or other urgent results will be missed when that doctor is absent; (2) Without a robust system for cross-cover 52 weeks per year recognised within another doctor’s job plan, this risk will likely continue, despite huge positive strides in communicating test results within the Trust. ”

    Source location

    Joan Marilyn READ · 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

    Develop a POPS cross-cover rota.

    Verbatim wording from the response

    “Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)”

    Source location

    2026-0055 - Response from Cardiff and Vale University Health Board
    Page 2 · response
    Published 4 February 2026

    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

    Prioritise consultant workforce expansion to support 52-week POPS service continuity.

    Verbatim wording from the response

    “Expansion of the POPS Service – Sustainable Long-Term Plan (In Progress)”

    Source location

    2026-0055 - Response from Cardiff and Vale University Health Board
    Page 2 · response
    Published 4 February 2026

    Open published response

  2. Suffolk

    AI-generated summary

    Denise Ellen 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

    Denise Ellen Johnson was admitted to hospital with abdominal pain and jaundice, underwent ERCP with stent insertion, and subsequently developed severe acute necrotising pancreatitis. Despite intensive supportive care, drainage, antibiotics and other treatment, she died on 24 November 2022; the inquest recorded multi-organ failure, severe E. coli septicaemia, pancreatic necrosis and ischaemic bowel perforation. The principal concerns were delayed notification and formal review of serious ERCP complications, inadequate communication with the next of kin and family about management plans, and unclear consultant cover during unexpected leave, each identified as posing a significant risk to patient safety.

    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 over named Surgical Consultant cover for surgical inpatients during unexpected leave

    Wider context from the report

    “Lack of clarity over named Surgical Consultant cover with responsibility for surgical inpatients during periods of unexpected leave ”

    Source location

    Denise Ellen 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

    Approve a cross-site SOP addressing patient cover during unexpected general surgery consultant leave.

    Verbatim wording from the response

    “A cross-site SOP has been drafted and approved since the Inquest entitled “Patient Take Over During Sickness Absence of a General Surgery Consultant” which addresses cover for patients in the circumstance of unexpected consultant leave.”

    Source location

    Response from East Suffolk and North Essex Foundation Trust
    Page 2 · response
    Published 17 January 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

    Embed the approved consultant sickness-absence SOP within the surgical division.

    Verbatim wording from the response

    “We will embed this SOP within the surgical division. Learning from both the incident and the new SOP will be used to drive improvement Trust wide.”

    Source location

    Response from East Suffolk and North Essex Foundation Trust
    Page 2 · response
    Published 17 January 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

    Remind colleagues that the on-call consultant can respond to acute deterioration or concerns when the named consultant is unavailable.

    Verbatim wording from the response

    “I can also provide assurance that there will be a more general reminder to all colleagues of the availability of the on call consultant to respond to acute deterioration/concern should the named consultant be unavailable.”

    Source location

    Response from East Suffolk and North Essex Foundation Trust
    Page 2 · response
    Published 17 January 2025

    Open published response

  3. Cumbria

    AI-generated summary

    Daphne Gillian AUSTIN · 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

    Daphne Gillian Austin, who was 71 and had diabetes, was admitted to hospital after a stroke. Her glucose levels were poorly controlled, she became dehydrated, and her fluid balance was not effectively monitored; blood testing was not carried out on 15 or 16 June 2023. She developed an acute kidney injury and then sepsis, and died on 18 June 2023. The principal concern was that planning for safe staffing during industrial action was insufficient, creating a risk of future deaths.

    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 industrial-action contingency planning to provide safe levels of clinical cover

    Wider context from the report

    “(1) I received evidence of the planning that had gone into preparing the trust for strikes. However, there was evidence from one of the Trust's consultants that on the day of the strike she had to "look after nearly 25 patients" and that "due to the junior doctor’s strike on 14/06/2023, Mrs Austin did not receive any medical input that day". Another consultant gave evidence that despite being listed as one of the consultants covering the unit (in the contingency planning evidence) he was probably dealing with other duties on that day. In the circumstances I am concerned that the planning that seeks to ensure safe levels of cover during periods of industrial action was insufficient to meet need and that this gave rise to a risk of future deaths. ”

    Source location

    Daphne Gillian AUSTIN · 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

    Maintain the existing industrial-action planning process and staffing plans for safe levels of medical cover during future industrial action.

    Verbatim wording from the response

    “The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:”

    Source location

    Response from North Cumbria Integrated Care NHS Trust
    Page 5 · response
    Published 13 August 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

    Existing industrial-action staffing processes and plans are considered sufficient to provide safe cover and will be maintained during future industrial action.

    Verbatim wording from the response

    “The Trust has reviewed the planning process and staffing plans and is satisfied that it ensures safe levels of cover during periods of industrial action to meet need, and that this does not give rise to a risk of future deaths. The process and plans will therefore be maintained during any future periods of industrial action. However, despite the Trust’s robust framework in ensuring appropriate medical cover during periods of industrial action, the Trust has identified areas of learning which could contribute to the Trust’s resilience:”

    Source location

    Response from North Cumbria Integrated Care NHS Trust
    Page 5 · response
    Published 13 August 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

    The Trust considers that staffing levels during industrial action did not cause or contribute to missed opportunities in the patient’s care.

    Verbatim wording from the response

    “In view of the Trust’s assurance that there is safe levels of cover during periods of industrial action to meet patient needs, the Trust is satisfied that this did not cause or contribute to any missed opportunities within Ms Austin’s care. However, the Trust unreservedly acknowledges that there is a need to establish what the causal and/or contributory factors were in Ms Austin not receiving medical input and basic, fundamental observations and interventions during her hospital admission. The Trust will therefore carry out a review into this to identify any learning and take immediate action to embed the learning to prevent recurrence and ensure that the care we provide is safe, effective, and of a high quality.”

    Source location

    Response from North Cumbria Integrated Care NHS Trust
    Page 6 · response
    Published 13 August 2024

    Open published response

  4. Manchester North

    AI-generated summary

    Teresa Chmielek · 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

    Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.

    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 referral cover during SPoE Nurse absence

    Wider context from the report

    “(5) The evidence was that there is no member of staff allocated to deal with referrals when the SPoE Nurse is absent from work which means that during their absence, urgent referrals are not being reviewed. ”

    Source location

    Teresa Chmielek · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Gwent

    AI-generated summary

    Mary Doreen 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

    Mary Doreen White was admitted to hospital in April 2021 and suffered three falls while an inpatient, including fractures requiring surgery. Her condition deteriorated while recovering from surgery, and she died from a chest infection, with frailty of old age also recorded. Concerns included staffing shortages, difficulties providing required enhanced observation on the ward, and the absence of a documented and communicated plan for managing patients requiring Level 4 enhanced care in that setting.

    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 a documented contingency plan for managing patients when staffing shortages prevent their assessed level of care

    Wider context from the report

    “1. Despite requesting additional nursing staff, the Bargoed ward was short-staffed when Mrs White fell. There did not appear to be any documented plan or procedure in place for how patients would be safely managed when it was not possible (because of staff shortage) to carry out the level of care for individual patients that they had been assessed as requiring. ”

    Source location

    Mary Doreen White · 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

    Introduce the Safecare Programme across wards covered by section 25B of the Nurse Staffing Levels (Wales) Act.

    Verbatim wording from the response

    “Furthermore, the Health Board are introducing the Safecare Programme on all wards under section 25B of the NSLWA. Safecare is a national programme currently being rolled out across all Health Boards in Wales. It matches staffing levels to patient acuity, providing control and assurance from bedside to board. It is designed to increase patient safety while maintaining efficiency and enables informed decisions to be taken at various levels of management.”

    Source location

    Response from Aneurin Bevan University Health Board
    Page 2 · response
    Published 20 February 2023

    Open published response

  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Patricia Violet PALIN · 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

    Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.

    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 a programme to replace unavailable A&E Doctors

    Wider context from the report

    “2. During the evening of the 1st October 2017, there were only two A&E Doctors on duty (a third had telephoned in sick ). Too few Doctors were therefore on duty in general to cover patient needs and there did not seem to be in place a programme for trying to get a third Doctor to replace the Doctor who had telephoned in sick. ”

    Source location

    Patricia Violet PALIN · 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

    Short-notice Emergency Department staffing gaps cannot always be covered because of workforce fragility and limited available doctors and agency staff.

    Verbatim wording from the response

    “The Trust does have a process in place for trying to backfill vacant shifts in the Emergency Department. At the first instance we will attempt to contact our own doctors via the Departmental Consultants or Medical Staffing representative making contact. We will also advertise via external agencies at the same time to ensure that every attempt is made to fill the gap. I attach a copy of the flow charts used to backfill vacant shifts.”

    Source location

    2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
    Page 1 · response
    Published 8 July 2018

    Open published response

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

Back to top

Data last updated 7 September 2026