Recurring concern

Unreliable allocation and completion of night-shift care tasks

First to latest report 29 Apr 2022 — 13 Sep 2024

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures in the dedicated night-shift task-management process, including unclear or incomplete task lists, unclear allocation of responsibility, agency-cover arrangements, lack of supervision and failure to verify completion of assigned care or welfare tasks.

What is not included
  • Excludes generic staffing shortages, fatigue or agency reliance unless they directly cause a failure in the night-shift task-allocation and completion process.
  • Excludes clinical treatment, patient observation or welfare-check failures where no night-shift task-management deficiency is identified.
  • Excludes general care-plan, handover, documentation or audit deficiencies that are not specifically tied to defining, assigning or completing night-shift care tasks.
  • Excludes non-care operational task lists and daytime task-allocation processes unless the assertion explicitly concerns the same night-shift care-task process.

Reports and published responses 4 reports

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

  1. Surrey

    AI-generated summary

    Paul Rodney Batchelor · 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

    Paul Rodney Batchelor, a frail elderly man in a care home for respite care, became wedged after a mattress extension fell through the frame of his extended nursing bed and died of positional asphyxia and bronchopneumonia. His cries for help went unattended for over an hour. The concerns were inadequate support for mattress extensions on extended beds and the lack of formalised procedures for staff responding to distressed residents at night, including when staff are frightened or concerned about entering a room alone.

    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 formalise resident room checks in care home policy and procedures

    Wider context from the report

    “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress. ”

    Source location

    Paul Rodney Batchelor · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Extend the Room Call Policy and Procedure to cover verbal calls for assistance and require physical checks without exceptions.

    Verbatim wording from the response

    “The staffing levels in the home were reviewed on 26 June 2023 and a change to the allocation of night staff was made to ensure all floors had care support throughout the night. Since the inquest concluded, we have communicated to all staff the coroner’s concerns and whilst we believe this was an isolated and unforeseeable occurrence, the home has continued to reinforce the learnings to the present time, being 16 months following the incident. A policy was in place at the time of the incident (the Room Call Policy and Procedure) for care staff to respond to call bells and has been extended to include if a resident was verbally calling out for assistance. The policy is that there is to be no exceptions ever to physically checking on a resident.”

    Source location

    Response from The Red House
    Page 4 · response
    Published 17 September 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 incident is considered isolated and unforeseeable, disputing the concern that similar failures may recur.

    Verbatim wording from the response

    “The staffing levels in the home were reviewed on 26 June 2023 and a change to the allocation of night staff was made to ensure all floors had care support throughout the night. Since the inquest concluded, we have communicated to all staff the coroner’s concerns and whilst we believe this was an isolated and unforeseeable occurrence, the home has continued to reinforce the learnings to the present time, being 16 months following the incident. A policy was in place at the time of the incident (the Room Call Policy and Procedure) for care staff to respond to call bells and has been extended to include if a resident was verbally calling out for assistance. The policy is that there is to be no exceptions ever to physically checking on a resident.”

    Source location

    Response from The Red House
    Page 4 · response
    Published 17 September 2024

    Open published response

  2. Norfolk

    AI-generated summary

    Eileen Marguerite WALSH · 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

    Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

    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 complete and define a night staff task list

    Wider context from the report

    “3. Evidence was heard that carers are responsible for work alongside caring for residents, including cleaning and laundry, A Night Tasks List was referred to as being “currently under review” and under the heading “Actions” was included “Implement revised night staff task list” in an investigation carried out by Adult Safeguarding in an Adult Safeguarding Record from 2022. As at the date of the inquest this document was not complete. There was no evidence as to what this List would include. ”

    Source location

    Eileen Marguerite WALSH · 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

    Consolidate night-work guidance, checklists, handover requirements and alarm procedures within the Night Working Policy and Procedure.

    Verbatim wording from the response

    “II. Broadland View decided as a part of continuous improvement to have some enhanced actions they could take, to bring together the learning and information that night staff specifically need, into this policy.”

    Source location

    Response from Broadland View Care Home
    Page 1 · response
    Published 4 August 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require staff to communicate and manage laundry and medication-room work so resident care, alarm audibility and staff availability are maintained.

    Verbatim wording from the response

    “III. Medication is administered from a mobile secure medication trolley, and the only time that the Senior carer is in the Medication Room is to collect and return the trolley. They are instructed to have the door open whilst they collect and remove the trolley then close and lock it afterwards. Audits on controlled drugs and homely remedies is only completed when both management are on site ensuring that a senior member of staff is able to hear the alarm. Interim monitor system was installed into the medication room until the new monitoring system was fitted.”

    Source location

    Response from Broadland View Care Home
    Page 2 · response
    Published 4 August 2023

    Open published response

  3. Norfolk

    AI-generated summary

    Eliot HARRIS · 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

    Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

    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 allocate specific tasks to staff on night duty

    Wider context from the report

    “2) On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota ”

    Source location

    Eliot HARRIS · Prevention of Future Deaths report
    Page 2 · 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

    Failure to allocate a Nurse in Charge for each night’s rota

    Wider context from the report

    “2) On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota ”

    Source location

    Eliot HARRIS · 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

    Ensure each shift identifies a nurse in charge and allocates roles using the reviewed daily allocation process.

    Verbatim wording from the response

    “Clarity of role within a shift is important to ensure all the required actions are completed in an effective way. The ward has improved their processes which now ensures the nurse in charge is identified and roles allocated to the shift team members. To achieve this, the daily allocation form has been reviewed which clearly identifies the nurse in charge. In addition, the Matron oversees the off duty rota and delegates nurse-in-charge duties each shift. This is monitored by the Clinical Team Leader and Modern Matron. Additional to this aspect the trust is formulating a seminar on shift co-ordination and accountability this will be rolled out to all Charge Nurses including those joining from an agency, the timescale for sign off of this is three months.”

    Source location

    Response form Norfolk and Suffolk Foundation Trust
    Page 2 · response
    Published 3 October 2022

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Jamie Lee Bennett · 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

    Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.

    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

    Unclear allocation of task-list responsibilities during night-shift agency cover

    Wider context from the report

    “The evidence was unclear as to who will carry out actions on the task lists on a night shift when a Sodexo worker was replaced by agency staff. There is no audit process in place to ensure staff are carrying out tasks in accordance with the lists issued There are no written instructions on how to conduct welfare checks. There is no audit process in place to ensure staff are conducting welfare checks appropriately It is my opinion there is a risk that future deaths may occur unless there are: • Clear, written instructions on how to conduct welfare checks • Clarity around which member of staff will be responsible for which task list, particularly on a night shift when a Sodexo worker is replaced by agency staff • An audit process put in place to ensure staff are carrying out tasks in accordance with the lists issued and in particular are conducting welfare checks appropriately ”

    Source location

    Jamie Lee Bennett · Prevention of Future Deaths report
    Page 8 · 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