Recurring concern

Insufficient staffing capacity for required one-to-one patient support

First to latest report 21 Apr 2015 — 24 Apr 2026

Reports that mention this concern
9
Times this concern has been raised
10
Stated actions linked to this concern
8

What this concern includes

Includes deficiencies in staffing levels, cover, deployment or contingency capacity that leave patients assessed as requiring one-to-one support without that support, including failures affecting one-to-one observation, therapeutic talk time or equivalent dedicated patient assistance.

What is not included
  • Excludes general staffing shortages where no requirement for one-to-one patient support is identified.
  • Excludes failures in the quality, planning or delivery of one-to-one care where staffing capacity is not the shared unsafe condition.
  • Excludes generic patient observation or supervision failures that do not involve a staffing-capacity deficiency for required one-to-one support.
  • Excludes staffing deficiencies in care homes, maternity services, prisons or other settings unless they directly leave patients without required one-to-one support.

Reports and published responses 9 reports

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

  1. 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.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide 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

    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

    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

  2. Nottinghamshire

    AI-generated summary

    Sophie Louise TOWLE · 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

    Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.

    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 staffing capacity on mental health wards

    Wider context from the report

    “5. Staffing on mental health wards I have been told by numerous witnesses to this inquest that the staffing levels on Fir Ward both at the time of Sophie’s admission, and now, are insufficient. The result of that, I am told, is that the wards cannot run safely and patient care and safety negatively impacted. Staff simply do not have time to complete essential tasks on the ward (like physical observations, completing care plans and risk assessments etc.) or give the patients the 1:1 time they require. I saw a genuine concern and regret on the faces of the hardworking healthcare professionals who gave evidence in my court of the course of this inquest, some were brought to tears. The job is relentless, and they do not feel supported by virtue of a lack of staff numbers and experience. I am told that this remains the case notwithstanding that the minimum staffing levels as governed by the Department of Health and Social Care are being met. This is an issue of grave concern. It suggests that the minimum levels of staff are too low, the staff pool is not sufficiently experienced across the board, that the wards are not functioning safely and that patients are at risk of death as a result. ”

    Source location

    Sophie Louise TOWLE · 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

    Streamline Matron attendance at Safe Care and Sit-Rep meetings while maintaining ward staffing and clinical-quality oversight.

    Verbatim wording from the response

    “The attendance at the Safe Care and Sit-Rep meetings has been streamlined so that the 4 inpatient Matrons take it in turns to attend with the expectation that the other Matrons are attending the board reviews and, on the wards, to review firsthand the staffing levels on the wards and to oversee clinical quality on the ward. Any concerns will also be escalated to the Head of Nursing and Associate Director of Nursing.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 15 · response
    Published 31 October 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

    MHOST establishments, daily staffing reviews and escalation arrangements are considered sufficient to meet ward clinical demands and address staffing shortfalls.

    Verbatim wording from the response

    “As discussed at the Inquest, the safe staffing tool identifies what staffing numbers are needed is set by NHS England via the Mental Health Optimal Staffing Tool, (MHOST). In October 2025, the Trust reviewed the staffing establishment tool (MHOST) which were agreed by the Ward Managers, Matrons and Nurse Directors to be sufficient to meet the clinical demands. This then reports to the board for oversight at the most senior level within the Trust.”

    Source location

    Response from Nottingham Healthcare NHS Foundation Trust
    Page 14 · response
    Published 31 October 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

    Responsibility for local mental health staffing and operations lies with the relevant trust, not the Government.

    Verbatim wording from the response

    “The Government is not able to comment on staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to improve care in NHS mental health services.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 31 October 2025

    Open published response

  3. Norfolk

    AI-generated summary

    Tracy Dawn WOOD · 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

    Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

    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 ward staffing for required one-to-one patient support

    Wider context from the report

    “1. Tracy Wood was placed on Yare Ward, an acute ward which was staffed in accordance with “Safer staffing levels”. We heard that additional staffing could be requested if necessary. The ward was described by witnesses as “busy” and at times “chaotic”. Staff were not always available to give Tracy one to one talk time which was recognised as being important to her and for her mental wellbeing, so much so a note was placed in red and bold on her SBAR records “If we are allocated to TW 1-1 we need to make sure we are doing it, she needs consistency”. Evidence was heard that steps are being taken to recruit more staff and also to retain existing staff and this is a national problem. The evidence was that the staffing levels are still not sufficient and that recruiting staff remains a problem ”

    Source location

    Tracy Dawn WOOD · 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 and retain inpatient staff to bring staffing within safe limits across clinical disciplines.

    Verbatim wording from the response

    “The Trust has committed to ensure that staffing on all our inpatient areas is within safe limits this includes nurses, support workers and other allied health professionals as well as medical staff. In response to vacancies, within the context of a national shortage and retention crisis of staff in the NHS, the Trust has embarked on an ambitious recruitment campaign which includes holding recruitment fairs across the region, attracting overseas nurses, social media campaigns, full page adverts in national newspapers, medical and nursing journals, continual refreshed adverts on the NHS Jobs website, incentives and improved development opportunities.”

    Source location

    Response from Hellesdon Hospital
    Page 1 · response
    Published 26 April 2022

    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

    Increase therapeutic inpatient activities, including one-to-one time, exercise, fitness and arts and crafts, through a quality improvement project.

    Verbatim wording from the response

    “The inpatient wards are part of a quality improvement project to enhance and increase therapeutic activities including 1:1 time, exercise and fitness, external and ward-based art and craft activities amongst other initiatives.”

    Source location

    Response from Hellesdon Hospital
    Page 1 · response
    Published 26 April 2022

    Open published response

  4. Blackpool and the Fylde

    AI-generated summary

    Barrie Keith Housby · 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

    Barrie Keith Housby, a hospital patient at high risk of falls, left his bed while the staff member assigned to observe him had temporarily left his bay and suffered a fatal fall. The report identified staffing shortages as contributing to the incident and raised concern that ongoing shortages at Clifton Hospital were putting elderly and vulnerable patients at risk.

    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

    Shortage of staff for required patient care tasks

    Wider context from the report

    “However, it was not disputed there are long – standing challenges in terms of staffing levels, notwithstanding efforts that have been and continue to be made in relation to recruitment of new staff. However, during this inquest the hospital staff could not have been clearer in their views: do to the reduction in staff numbers, they did not have enough time to carry out their expected tasks. As one HCA told the court, it was “impossible” to provide one to one nursing care to Mr Housby with the number of staff working that shift at that time. The court was told that since Mr Housby’s death, the problem of staffing shortages persists. My concern therefore is as follows: Clifton hospital is a place where patients – often elderly and vulnerable – are transferred for a period of rehabilitation, usually from an acute hospital setting. The aim usually is that following such rehabilitation they can hopefully return to their homes, or perhaps be discharged to a suitable care home. However, these patients are being put at risk due to a shortage of staff. ”

    Source location

    Barrie Keith Housby · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. South Wales Central

    AI-generated summary

    Edwina Rose Moses · 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

    Edwina Rose Moses was admitted to hospital after a fall at home that fractured her left hip. While in hospital, she fell from her bed at a time when she should have been receiving one-to-one nursing care, fractured her right hip, and later died following an upper gastrointestinal bleed; concerns included poor systems for arranging additional nursing cover and inadequate staffing when such cover was unavailable.

    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 additional nursing cover for one-to-one support

    Wider context from the report

    “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic. Given the apparent frequency in which additional nursing cover is “unavailable”, often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern. ”

    Source location

    Edwina Rose Moses · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate ward staffing levels for safely caring for patients

    Wider context from the report

    “2. The evidence showed that it was common place for additional nursing cover not to attend and staff were then left to provide one to one cover alongside their main stream duties – which was wholly unrealistic. Given the apparent frequency in which additional nursing cover is “unavailable”, often in the context of dealing with patients suffering with dementia, the issue of appropriate staffing levels on wards and the ability of staff to safely look after patients must be a concern. ”

    Source location

    Edwina Rose Moses · 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

    Establish daily staffing monitoring that identifies patients requiring enhanced observation, includes out-of-hours handover, and checks Nurse Bank availability.

    Verbatim wording from the response

    “The Princess of Wales Hospital Managed Unit has reviewed its process around enhanced observation. The review included the standard of completion of Risk Assessments and introducing a process to monitor staffing levels across the site which will include the identification of all patients requiring enhanced observation. There is daily monitoring of staffing levels in place which is subsequently handed over to the Out of Hours team for evenings and weekends. All staff have been made aware of the process to check the Nurse Bank system. This work will link into the Health Board Falls Management group as prevention of falls is one of the main criteria for requesting enhanced observation.”

    Source location

    2016-0462-Response-by-University-Health-Board.pdf
    Page 1 · response
    Published 22 December 2016

    Open published response

  6. South Wales Central

    AI-generated summary

    Maurice ISAACS · 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

    Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.

    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 ward staffing to manage care demands

    Wider context from the report

    “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation. Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis. Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward. His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated. The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls. ”

    Source location

    Maurice ISAACS · 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

    Restrict staff assigned to specialling to duties that do not take them away from providing specialling.

    Verbatim wording from the response

    “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 3 · response
    Published 9 February 2017

    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

    Benchmark enhanced observational care against other organisations across Wales and England.

    Verbatim wording from the response

    “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 3 · response
    Published 9 February 2017

    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

    Carry out the Specialling of Patients project in Medicine Clinical Board wards.

    Verbatim wording from the response

    “The UHB is currently carrying out a project on the ‘Specialling of patients’ which we hope to have in place in the Medicine Clinical Board ward areas in February 2017.”

    Source location

    2016-0411-Response-by-Uiniversity-Hospital-of-Wales
    Page 3 · response
    Published 9 February 2017

    Open published response

  7. West Sussex

    AI-generated summary

    Amy El-Keria · 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

    Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.

    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

    Inadequate staffing levels for one-to-one care in inpatient CAMHS units

    Wider context from the report

    “(1) The Jury in this Inquest found that the staffing levels, which were in line with the ONIC staffing ratio, were inadequate to give Amy sufficient one to one time in accordance with her care plan. It is understood that in December 2014 the Department of Health tasked NICE with developing guidance on staffing levels for inpatient CAMHS units but this appears to have been discontinued. There is currently no national guidance on staffing levels for inpatient CAHMS ”

    Source location

    Amy El-Keria · Prevention of Future Deaths report
    Page 1 · 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

    Existing staffing reviews, multidisciplinary support, on-call arrangements and staff redeployment are considered sufficient to determine appropriate staffing levels.

    Verbatim wording from the response

    “We note your comments in relation to the QNIC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

    Source location

    2016-0347-Response-by-Priory-Group
    Page 1 · response
    Published 3 October 2016

    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 guidance, continual staffing reviews, multidisciplinary support and escalation arrangements are considered sufficient to determine appropriate staffing levels.

    Verbatim wording from the response

    “We note your comments in relation to the QNІC guidance published by the Royal College of Psychiatrists and we consider that this is still an appropriate reference point for the staffing of CAMHS units and continues to be used by many providers in determining and monitoring appropriate staffing levels.”

    Source location

    2016-0347 - Response from Priory
    Page 1 · response
    Published 3 October 2016

    Open published response

  8. Inner West London

    AI-generated summary

    Leslie Douglas Murray · 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

    Leslie Douglas Murray, who required 1:1 nursing care, fell from his hospital bed when adequate cover was unavailable and sustained injuries that led to his death the following day. The principal concern was insufficient staffing to provide 1:1 care, resulting in preventable falls or other care deficiencies that could cause or contribute to death.

    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 cover for required 1:1 patient care

    Wider context from the report

    “(1) That insufficient cover is provided to allow 1:1 care to be given to patients that require it on this ward (Holdsworth) and likely others throughout the hospital, and as such patients are suffering preventable falls that may be causing fatal injury, or suffering other care deficiencies that may cause or contribute to death. ”

    Source location

    Leslie Douglas Murray · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Howell Glyndwr Fisher · 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

    Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.

    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 staffing for required one-to-one nursing observation of patients at high risk of falls

    Wider context from the report

    “(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered. ”

    Source location

    Howell Glyndwr Fisher · 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.

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Data last updated 7 September 2026