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. Essex

    AI-generated summary

    Katharine Emma Corrigan · 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

    Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

    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 qualified and clearly designated nurse-in-charge cover

    Wider context from the report

    “8. Preceptorship nurses were left in charge on the mental health ward on the morning of 22 July 2023 and a qualified nurse attended several hours after the commencement of the shift. This was known about and management staff did not check that the arrangements to mitigate this had been facilitated. There was no clear understanding of how and by whom the nurse in charge role was being undertaken. This contributed to Ms Corrigan accessing the community when leave had been removed temporarily by the ward manager the previous evening in accordance with protocol. The medical records were not clearly updated to reflect this, and the Section 17 Leave form had not been updated. ”

    Source location

    Katharine Emma Corrigan · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Essex

    AI-generated summary

    Abigail Louise SMITH · 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

    Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from 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

    Insufficient trained staffing for enhanced observations of patients at risk of severe self-harm

    Wider context from the report

    “1. There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life. ”

    Source location

    Abigail Louise SMITH · 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

    Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.

    Verbatim wording from the response

    “I understand that the Court has been provided with an updated copy of the Trust’s Policy for Enhanced Supervision and Engagement. This policy strengthens our assessment and guidance for patients requiring enhanced supervision as per the attached tool.”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 2 · response
    Published 13 August 2026

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    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

    Include enhanced supervision in mandatory training for staff providing enhanced supervision to patients.

    Verbatim wording from the response

    “Enhanced Supervision is part of mandatory training for all staff who are involved with providing enhanced supervision to patients.”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 3 · response
    Published 13 August 2026

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for mental health team staffing falls within Essex Partnership University Foundation Trust's remit, not this Trust's.

    Verbatim wording from the response

    “We acknowledge the concerns of HM Coroner that lack of staffing led to the provision of a security guard in order to support the Mental Health Team. We have not identified any evidence of a Trust-employed security staff being allocated to patients that night, as would usually be documented. In any event, we are not able to comment on staffing of the mental health team or how that fell within the remit of Essex Partnership University Foundation Trust (EPUT).”

    Source location

    Response from Mid & South Essex NHS Foundation Trust
    Page 1 · response
    Published 13 August 2026

    Open published response

  3. East Riding and Hull

    AI-generated summary

    Kenneth John Morris · 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

    Kenneth John Morris, aged 78, died at Hull Royal Infirmary on 10 December 2025 after a second unwitnessed ward fall caused intracranial haemorrhage, brain damage and early post-traumatic epilepsy. The principal concern was that he did not receive required one-to-one nursing care because of understaffing and more pressing cases, and evidence indicated that similar deaths may occur while resources remain critically stretched.

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    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 required one-to-one nursing care

    Wider context from the report

    “This gentleman should have received one to one nursing care but due to a combination of understaffing and more pressing cases on the ward, he did not receive such care. Evidence was heard that had he received such care he would not have fallen and died. Evidence was also heard that within the Hull Trust and probably throughout the NHS, resources are critically stretched and whilst improvements are being proposed, I believe that the current situation makes it probable that similar deaths will occur. ”

    Source location

    Kenneth John Morris · 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

    Publish a new 10 Year Workforce Plan to support appropriate NHS staffing and workforce distribution.

    Verbatim wording from the response

    “In our 10 Year Health Plan we committed to publishing a new 10 Year Workforce Plan. The plan, which will be published this year, will help ensure the NHS has the right people in the right places to deliver the best care for patients.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 19 June 2026

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    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

    Individual NHS trusts and employers are responsible for determining staffing levels and workforce composition.

    Verbatim wording from the response

    “I have carefully considered the situation. Individual NHS Trusts and other employers are responsible for determining staffing levels and workforce composition. They are best placed to understand their services and the needs of their patients in order to deliver safe and effective care. I would expect Hull University Teaching Hospitals NHS Trust and all other NHS Trusts to ensure that their staffing arrangements, are appropriate following the tragic death of Mr Morris.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 19 June 2026

    Open published response

  4. Essex

    AI-generated summary

    Elise Kay Louise Sebastian · 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

    Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

    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

    Inexperienced ward staffing for detained children

    Wider context from the report

    “1. Mental Health Trust Staff on Longfield Ward: a. Elise was neurodiverse and staff were not trained in Autism b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021. c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised. d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly. e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward. f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated. g. Not all the Trust staff on the ward were trained to use the Oxevision System. h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward. ”

    Source location

    Elise Kay Louise Sebastian · 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

    Implement staffing controls requiring appropriately skilled and inducted bank and agency staff, supported by rota review and competency oversight.

    Verbatim wording from the response

    “• A review of Rotas undertaken to ensure staffing requirements met including right staff with right training and competency skills.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement enhanced escalation and local induction processes when CAMHS roster requirements or staff competencies are insufficient.

    Verbatim wording from the response

    “• The formulation of an enhanced escalation process when roster requirements are not met. This has been shared across all inpatient services.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Increase CAMHS staffing capacity and strengthen leadership through additional shift staff, retention premiums, new management and preceptor-support roles, and activity coordinators.

    Verbatim wording from the response

    “• The provision of a retention premium for band 5’s posts”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 2 · response
    Published 13 February 2026

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    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

    Continue developing CAMHS preceptorship and workforce planning, and use the Mental Health Optimal Staffing Tool across the Trust.

    Verbatim wording from the response

    “• Work has continued to develop staff and the CAMHS Preceptorship programme in place, guided practice development framework, led by band 6 practice development role.”

    Source location

    2026-0078 - Response from Essex University Partnership Trust
    Page 3 · response
    Published 13 February 2026

    Open published response

  5. East Riding and Hull

    AI-generated summary

    Mrs Patricia Irene Walker · 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 Irene Walker suffered a fractured neck of femur after a fall, followed by further falls in hospital, including a fall that resulted in an acute bilateral subdural haematoma. She was later discharged to a care home on a fast-track basis and died after poor nutritional intake, medication refusal and worsening confusion; the report raised concerns about suboptimal staffing on Ward 90 and increased falls risk.

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    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 maintain adequate staffing for TAG nursing care

    Wider context from the report

    “(1) Staffing was sub optimal and remain sub optimal on Ward 90 as recruitment is difficult which means that TAG nursing care is not always possible, and patients are at an increased risk of falls. ”

    Source location

    Mrs Patricia Irene Walker · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Operate daily site staffing meetings and twice-daily Trust-wide safe staffing reviews to identify staffing risks and redistribute workforce to priority areas.

    Verbatim wording from the response

    “The Trust has established daily operational controls to mitigate staffing pressures in real time. Daily staffing meetings take place across all sites, where ward-level escalations relating to actual versus planned staffing, changes in acuity, and red flag indicators are reviewed by dedicated staffing representatives. These representatives cover all Trust sites, providing a consistent view of risk and enabling rapid redistribution of workforce to the highest priority areas.”

    Source location

    2026-0044 - Response from Hull University Teaching Hospital
    Page 1 · response
    Published 29 January 2026

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    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 24/7 site-matron oversight of staffing escalations, including authorising redeployment, temporary staffing and enhanced-care arrangements outside core hours.

    Verbatim wording from the response

    “Out of hours, staffing escalations are directed to site matrons who provide senior clinical leadership 24 hours a day, 7 days a week, and who review and authorise redeployment, temporary staffing requests and enhanced care arrangements during evenings, nights and weekends, ensuring continuous oversight and rapid response to any deterioration in staffing levels or patient acuity outside core hours.”

    Source location

    2026-0044 - Response from Hull University Teaching Hospital
    Page 2 · response
    Published 29 January 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

    Complete a safer staffing establishment review using recognised staffing tools and triangulation with patient outcomes to identify staffing gaps and prioritise investment.

    Verbatim wording from the response

    “In addition to the above, as part of a wider programme to strengthen safe staffing and reduce reliance on temporary mitigation, the Trust (as part of Humber Health Partnership) has undertaken a comprehensive safer staffing establishment review using recognised safer staffing tools (including the Safer Nursing Care Tool census approach) and triangulation with patient outcomes.”

    Source location

    2026-0044 - Response from Hull University Teaching Hospital
    Page 2 · response
    Published 29 January 2026

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    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 nursing establishment investment for priority red-rated areas, including the recommended Ward 90 healthcare-assistant uplift.

    Verbatim wording from the response

    “• that funding the “red” areas would require investment, equating to 123.82 WTE, and that this is intended to support safer care delivery and reduce premium “bad cost” spend by moving to substantive recruitment where possible.”

    Source location

    2026-0044 - Response from Hull University Teaching Hospital
    Page 2 · response
    Published 29 January 2026

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    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 the approved safer-staffing investment in phases, prioritising red-rated areas and aligning recruitment with affordability planning.

    Verbatim wording from the response

    “While the Trust’s actions are Trust-wide and intended to improve safety across multiple wards/services, the approved investment recommendations do include Ward 90, which is identified as SNCT Red with a recommended uplift the number of Health Care Assistant 12 hours per day.).”

    Source location

    2026-0044 - Response from Hull University Teaching Hospital
    Page 3 · response
    Published 29 January 2026

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    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 staffing and TAG nursing concerns fall outside NHS England’s usual role and remit.

    Verbatim wording from the response

    “We note that your Report has also been sent to Hull University Teaching Hospitals NHS Trust, who would be best placed to respond to your concerns from a local perspective. NHS England has endeavoured to address your concerns as far as we are able to, but consider the issues in this case to fall outside of our usual role and remit.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 29 January 2026

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    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

    Hull University Teaching Hospitals NHS Trust is responsible for its own recruitment and should address related queries.

    Verbatim wording from the response

    “NHS provider organisations have a statutory duty to ensure that services are staffed safely and appropriately to meet the clinical needs of patients. Each Trust or NHS organisation is responsible for its own recruitment and therefore any future queries in this regard will be best addressed by Hull University Teaching Hospitals NHS Trust.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 29 January 2026

    Open published response

  6. North Wales (East and Central)

    AI-generated summary

    Rory Colin Williams · 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

    Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.

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    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 of the gastroenterology and endoscopy service

    Wider context from the report

    “It was accepted by the Health Board that there had been a delay between April 2024 and July 2024 in undertaking the endoscopy. Whilst this did not impact on the outcome for Rory Williams it did highlight a number of ongoing concerns with the gastroenterology / endoscopy service:- a. Staffing – the evidence at Inquest was that the Health Board was struggling to maintain this most basic service at Ysbyty Glan Clwyd due to staffing issues which included lack of consultants, endoscopists and other essential healthcare staff. There is currently only one full time equivalent consultant and 3 locums. The service is currently considered to be ‘absolutely dependent on locums’. It was noted that recruitment into gastroenterology is a challenge yet these issues have been ongoing for many considerable years, potentially since 2018. b. Infrastructure – evidence was heard that this requires significant investment and improvement within the service, and despite business cases having been made there have not been significant steps to improve this. It is not known why. c. The Health Board’s target for urgent suspected cancer referrals to endoscopy (that is from GP referral to endoscopy) is 21 days. Today, this stands at 8 weeks. d. The Health Board’s current wait time for urgent referrals (non-suspected cancer) to endoscopy is currently 89 weeks. This figure has increased since 2023. e. The Health Board’s current wait time for routine referrals to endoscopy is currently 148 weeks. This figure has increased since 2023. f. I am concerned that there is no fully networked service for endoscopy / gastroenterology where this and the above concerns do not appear on the corporate risk register. Whilst they appear on the local risk register it is extremely concerning that corporately it does not appear as a risk. Evidence was heard that at one point the risk score for the service was reduced from 25 to 20. The reason is not known. g. The overall impression is that the service is not fit for purpose and that all of these concerns, many of which have existed for several years, signify a risk of harm and death of patients into the future as a result. ”

    Source location

    Rory Colin Williams · 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

    Recruit substantive gastroenterology and endoscopy staff through Health Board-wide advertisements.

    Verbatim wording from the response

    “The Health Board acknowledges the challenges associated with recruiting and retaining gastroenterology consultants and endoscopists, an issue experienced across the UK. In our Health Board, these challenges have affected service resilience, particularly at Ysbyty Glan Clwyd, where staffing gaps have necessitated reliance on locum support.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 20 January 2026

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    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 sustainable workforce models using multidisciplinary roles, cross-site working and alternative diagnostic pathways.

    Verbatim wording from the response

    “Active recruitment to substantive posts continues across the Health Board with advertisements now being for the whole Health Board rather than individual sites to help strengthen resilience. In parallel, work is underway to develop more sustainable workforce models, including greater use of multidisciplinary roles, cross-site working, and alternative pathways designed to reduce pressure on consultant capacity whilst maintaining patient safety. Capsule sponge endoscopy has been introduced at Wrexham Maelor; this is less invasive than endoscopy and can be used in certain diagnostic circumstances. This will be rolled out across the Health Board.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 20 January 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

    Conduct a Rapid Quality Review of Gastroenterology Services to identify risks and agree mitigating actions.

    Verbatim wording from the response

    “In response to a series of quality, performance and workforce concerns raised during 2024 and 2025, I convened a Rapid Quality Review of Gastroenterology Services on 13 February 2026.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 20 January 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

    Develop an Integrated Digestive Disease Service with shared leadership, standardised pathways, coordinated workforce planning and strengthened governance.

    Verbatim wording from the response

    “Work is therefore progressing on the development of an Integrated Digestive Disease Service, with shared clinical leadership, standardised pathways, coordinated workforce planning and strengthened governance. This programme of work is being taken forward under executive sponsorship, with follow-up reviews scheduled to monitor progress and ensure delivery of agreed actions.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 20 January 2026

    Open published response

  7. Manchester South

    AI-generated summary

    Alan Paul Peet · 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

    Alan Paul Peet, who was quadriplegic following an accidental fall, was admitted to hospital after his condition deteriorated at Acer Mews Care Home on 26 July 2025. He was found to be septic, possibly due to bronchopneumonia, and died at Tameside General Hospital on 28 July 2025. Concerns included inadequate observation and record-keeping, lack of clear management oversight of tracheostomy-trained nursing cover, and agency staff lacking access to electronic systems.

    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 tracheostomy-trained nursing cover for residents requiring tracheostomy support

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”

    Source location

    Alan Paul Peet · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. West Yorkshire (Western)

    AI-generated summary

    Alan HORROCKS · 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

    Alan Horrocks was admitted to hospital on 19 February 2025 with a suspected stroke, later diagnosed as viral encephalitis. He deteriorated, developing a Hyperosmolar Hyperglycaemic State and an upper gastrointestinal haemorrhage, and died on 17 March 2025 after treatment was withdrawn. The hospital investigation identified that overnight observations were not completed in accordance with escalation guidance and raised concerns about increased ward capacity without a corresponding increase in nursing establishment, alongside gaps in the existing nursing establishment.

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    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 establishment for ward bed capacity

    Wider context from the report

    “Following Mr Horrocks death an investigation was undertaken by the hospital, the report in respect thereof being provided to the court late on the afternoon 22 October 2025. The hospital investigation identified inter alia that observations were not completed on the ward overnight on 14 March 2025 in accordance with escalation guidance with no documented reason. Whilst the evidence did not identify Mr Horrocks "baseline" NEWS score, evidence at the inquest hearing from consultants involved in Mr Horrocks care identified a NEWS score of 5 required further observations and possible escalation. Further, that it was likely that there was an ongoing deterioration from late on 14 march 2025 into 15 March 2025 which was only appreciated further observations were undertaken shortly before midday on 15 March 2025 identifying an increase in the NEWS score to 12. The evidence indicated however that in Mr Horrocks case, even if his deterioration had been identified sooner, on a balance of probabilities, it would not have avoided his death when it occurred. The hospital investigation also identified that during this period the ward bed capacity had been increased from 27 to 33 beds owning to winter pressures with no corresponding change to the nursing establishment on the ward. Further, during this period there were gaps in the existing nursing establishment on the ward. Whilst the hospital investigation had identified these matters, there were no recommendations that these were issues for wider learning or how, if at all, these issues were to be addressed. ”

    Source location

    Alan HORROCKS · 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

    Staffing levels exceeded the planned ratios for Ward 6’s expanded bed capacity, which the Trust says ensured safe and appropriate care.

    Verbatim wording from the response

    “On 14th March 2025 the ward operated with 33 beds. Every year the number of patients requiring hospital admission increases, particularly during periods of seasonal pressure. To manage this demand the Trust implements a Winter Escalation Plan that includes opening additional beds. On Ward 6 this involves opening an extra bay of six beds and allocating additional staff specifically for these patients. As a result the established staffing levels rise from five Registered Nurses and five Health Care Assistants, to six Registered Nurses and six Health Care Assistants per shift, ensuring safe and appropriate care for the expanded patient cohort.”

    Source location

    Response from Bradford Teaching Hospitals
    Page 4 · response
    Published 29 October 2025

    Open published response

  9. Inner North London

    AI-generated summary

    Mary Anne FITZPATRICK · 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 Anne Fitzpatrick was discharged from hospital on 29 January 2025 and received district nursing care. A sacral pressure sore progressed from category 2 to category 4, leading to readmission on 27 February, deconditioning and her death. Concerns included the frequency and adequacy of wound dressing visits, the development and treatment of the pressure sore, and insufficient reflection by the district nursing team after her death.

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    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 for safe transfer of elderly patients

    Wider context from the report

    “1. It is well recognised that the admission of an elderly person to hospital can be risky and should only be undertaken if really necessary. These days, a long wait on a hospital trolley is predictable. Even without that, the elderly are known often to decondition quickly. At inquest I accepted the evidence of Mrs Fitzpatrick’s family that the reality of her admission to the Whittington on 23 January 2025 was that it was undertaken because there was only one nurse attending her on that day and this nurse felt she could not transfer this small, elderly lady alone with the aids that were available. ”

    Source location

    Mary Anne FITZPATRICK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Surrey

    AI-generated summary

    Tracey Ostler · 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

    Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

    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 appropriately trained mental health nurses for acute psychiatric patients

    Wider context from the report

    “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care 1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed. 2. I remain concerned that there in no plan to stop this practice and that therefore: a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team. b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients. c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients. d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician. e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area. f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. ”

    Source location

    Tracey Ostler · Prevention of Future Deaths report
    Page 5 · 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 24-hour Mental Health Support Worker coverage, including de-escalation, therapeutic engagement and support for patients with complex needs.

    Verbatim wording from the response

    “• Mental health support workers have been recruited, with specific training and expertise to support mental health patients”

    Source location

    Response from Epsom General Hospital
    Page 4 · response
    Published 13 August 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

    Deliver mental-health training to emergency-department nursing and medical teams through collaboration with Psychiatric Liaison Teams.

    Verbatim wording from the response

    “The Trust’s nursing and clinical teams working with the ED are not trained mental health professionals. Through working with Psychiatric Liaison Teams with this experience, training has been delivered to nursing and medical teams, to ensure our staff at the Trust are equipped with the skills to support mental health patients whilst they are at the Trust.”

    Source location

    Response from Epsom General Hospital
    Page 4 · response
    Published 13 August 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

    Launch an investigation into mental health crisis care for patients in emergency departments, covering resources, environments, and admission or discharge decisions.

    Verbatim wording from the response

    “Mental Health Crisis: Care of patients in emergency departments”

    Source location

    Response from Health Service Safety Investigations Body
    Page 2 · response
    Published 13 August 2025

    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

    Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.

    Verbatim wording from the response

    “Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust.”

    Source location

    Response from Epsom General Hospital
    Page 2 · response
    Published 13 August 2025

    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

    Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.

    Verbatim wording from the response

    “NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.”

    Source location

    Response from Epsom General Hospital
    Page 2 · response
    Published 13 August 2025

    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

    Clinical matters fall outside the commissioning organisation’s remit.

    Verbatim wording from the response

    “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

    Source location

    Response from NHS South West London Integrated Care Board
    Page 1 · response
    Published 13 August 2025

    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

    Clinical matters are the responsibility of the relevant Trusts.

    Verbatim wording from the response

    “As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below.”

    Source location

    Response from NHS South West London Integrated Care Board
    Page 1 · response
    Published 13 August 2025

    Open published response

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