PFD report

Macloud Nyeruke · Prevention of Future Deaths report

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Issued 18 Sep 2020•West Yorkshire Eastern

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to provide and verify appropriate PPE training before infectious-disease ward work
  2. Failure to preserve records of appropriate PPE training
    Part of recurring concern: Failure to maintain training records that verify staff competence
  3. Lack of information about staff members’ medical conditions
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. Action

    Investigate the matter under the Employment Agencies Act 1973 and associated Conduct Regulations, including agencies’ checks, authorisations and work-seeker protections.

    Stated by Employment Agency Standards Inspectorate, Economics and Markets Group, BEISStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.
  2. Action

    Audit subcontractor compliance with required occupational health checks and PPE training.

    Stated by Reed Specialist Recruitment LimitedStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  3. Action

    Standardise shift booking notes across the Trust so high-risk areas specify that bank and agency workers must be fit tested before attending.

    Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.8

  1. Position

    Reed says it fulfilled contractual obligations and audited subcontractor health checks and PPE training for supplied workers.

    Stated by Reed Specialist Recruitment LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide and verify appropriate PPE training before infectious-disease ward work

Wider context from the report

“(2) There is scant evidence as to whether Mr Nyeruke underwent appropriate training in respect of PPE such as masks before being permitted to work on a ward involving infectious diseases. The difficulties involved (where a support worker supplied by a nursing agency is only in the hospital for a brief period) are acknowledged. Nonetheless, the risk of an adverse transmission of infection either to, or from, the staff member necessitates stringent standards being enforced, with appropriate records preserved. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to preserve records of appropriate PPE training

Wider context from the report

“(2) There is scant evidence as to whether Mr Nyeruke underwent appropriate training in respect of PPE such as masks before being permitted to work on a ward involving infectious diseases. The difficulties involved (where a support worker supplied by a nursing agency is only in the hospital for a brief period) are acknowledged. Nonetheless, the risk of an adverse transmission of infection either to, or from, the staff member necessitates stringent standards being enforced, with appropriate records preserved. ”

Is this part of a recurring concern?

Yes — Failure to maintain training records that verify staff competence.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of information about staff members’ medical conditions

Wider context from the report

“(1) Mr Nyeruke’s medical conditions were not made known to the Trust. In consequence, he had worked on wards where patients had infections involving multi-resistant organisms. Given his compromised immune state, this situation involved risk to both patients and Mr Nyeruke himself. In the absence of information concerning a particular staff member’s medical condition there is an increased risk of transmission of infections either to or from the staff member. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of nursing agencies to provide hospitals with support workers’ work locations

Wider context from the report

“(3) Nursing agencies which supply support workers to hospitals without knowledge of their particular health vulnerabilities, or where they will be working, give rise to a risk that they may be adversely affected or may give rise to adverse effects on patients or colleagues. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of nursing agencies to provide hospitals with support workers’ health vulnerabilities

Wider context from the report

“(3) Nursing agencies which supply support workers to hospitals without knowledge of their particular health vulnerabilities, or where they will be working, give rise to a risk that they may be adversely affected or may give rise to adverse effects on patients or colleagues. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Investigate the matter under the Employment Agencies Act 1973 and associated Conduct Regulations, including agencies’ checks, authorisations and work-seeker protections.

Verbatim wording from the response

“We will investigate this matter further in accordance with the legislative framework of the Employment Agencies Act 1973 and associated Conduct Regulations.”

Source location

2020-0177-Response-from-Employment-Agency-Standards_Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Audit subcontractor compliance with required occupational health checks and PPE training.

Verbatim wording from the response

“At the point when Mr Nyeruke was first introduced to LTHT this was via ID Medical in November 2016, as prior to Reed's involvement with LTHT ID Medical had a contract direct with the Trust and not a sub-contractual arrangement via Reed. Reed then entered into a sub-contracting arrangement with ID Medical in January 2019 as part of Reed then managing the staff bank, for the supply of Mr Nyeruke. After having thoroughly investigated the matter, I can confirm that Reed has fully complied with its contractual obligations towards LTHT and received confirmation from ID Medical to confirm that Mr Nyeruke was suitably vetted and medically fit to commence the temporary assignment at LTHT. Moreover, Reed did also perform the necessary audits on ID Medical to confirm that the required health checks and training (in relation to PPE) for Mr Nyeruke were performed.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 1 · response
Published 19 November 2020

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

Standardise shift booking notes across the Trust so high-risk areas specify that bank and agency workers must be fit tested before attending.

Verbatim wording from the response

“In addition to the above, some wards are adding ‘bank notes’ to shifts that need covering specifying that the bank or agency staff member must be fit tested prior to attending the shift. Bank notes are accessible by bank and agency workers when booking the shift. We plan to standardise this approach Trust-wide so that high risk areas routinely add this to any shifts going out to bank and agency staff. To reassure ourselves that this is working we plan to audit the number of staff with the fit tested skill attached to Health Roster in the high-risk areas, including Infectious Diseases.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Advise vulnerable or high-risk bank and agency workers to check ward status and carry their risk assessment when potential ward moves arise.

Verbatim wording from the response

“During our discussions we explored whether there was any way we could prevent high risk/vulnerable workers from viewing available shifts where a ‘general skill’ such as being fit tested or having IV drug competency is attached. We concluded that the system would not allow us to do this; however, all bank and agency staff assessed as being high risk or vulnerable have been advised to call Reed to check the status of a ward during Covid. All bank and agency staff classed as vulnerable or high risk have been advised to carry with them a copy of their risk assessment in case of any potential ward moves once their shift commences.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Strengthen assurance that agency workers are fit tested before high-risk placements by obtaining verification, recording fit-testing status, and providing additional fit testing.

Verbatim wording from the response

“In response to point 2 the Trust acknowledges that there was no documentary evidence to support Mr Nyeruke’s confirmation that he had been fit tested prior to working on J20. Following receipt of your PFD report the Trust has been in discussions with Reed with a view to obtaining more robust assurance that an agency staff member has undergone Fit testing prior to working in an area where FFP 3 masks are required.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Audit high-risk areas, including Infectious Diseases, to verify the number of staff with fit-testing status recorded in Health Roster.

Verbatim wording from the response

“In addition to the above, some wards are adding ‘bank notes’ to shifts that need covering specifying that the bank or agency staff member must be fit tested prior to attending the shift. Bank notes are accessible by bank and agency workers when booking the shift. We plan to standardise this approach Trust-wide so that high risk areas routinely add this to any shifts going out to bank and agency staff. To reassure ourselves that this is working we plan to audit the number of staff with the fit tested skill attached to Health Roster in the high-risk areas, including Infectious Diseases.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 3 · response
Published 19 November 2020

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

Reed says it fulfilled contractual obligations and audited subcontractor health checks and PPE training for supplied workers.

Verbatim wording from the response

“At the point when Mr Nyeruke was first introduced to LTHT this was via ID Medical in November 2016, as prior to Reed's involvement with LTHT ID Medical had a contract direct with the Trust and not a sub-contractual arrangement via Reed. Reed then entered into a sub-contracting arrangement with ID Medical in January 2019 as part of Reed then managing the staff bank, for the supply of Mr Nyeruke. After having thoroughly investigated the matter, I can confirm that Reed has fully complied with its contractual obligations towards LTHT and received confirmation from ID Medical to confirm that Mr Nyeruke was suitably vetted and medically fit to commence the temporary assignment at LTHT. Moreover, Reed did also perform the necessary audits on ID Medical to confirm that the required health checks and training (in relation to PPE) for Mr Nyeruke were performed.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 1 · response
Published 19 November 2020

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

Reed cannot investigate underlying medical declarations or fully scrutinise subcontractor training content beyond issued clearance certificates.

Verbatim wording from the response

“Both contractually and legislatively the responsibility on ID Medical was to carry out an occupational health assessment and training. I can confirm Reed have seen evidence of this dating back to 2012 which falls in line with when Mr Nyeruke first engaged with ID Medical. However, Reed are unable to investigate the detailed evidence beyond the health clearance such as the medical declarations made by Mr Nyeruke, and other supporting evidence that underpin the occupational health fitness to work certificate, nor can we fully scrutinise the training content that sits behind the certificates. This is a matter for the regulator and Crown Commercial Service, which is why we escalated this matter to them within 24/76 hours of receiving your initial report.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 1 · response
Published 19 November 2020

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

ID Medical, as employer and supplier, should receive the report and take additional measures to protect temporary workers supplied through its arrangements.

Verbatim wording from the response

“My suggestion to re-address the Regulation 28 Report to ID Medical was made on the basis that Reed is unable to take any steps other that I have set out above in relation to individuals supplied by sub-contractors and that ID Medical as the employer/supplier, should be made aware of this Report in order to take additional measures (you deem fit) to protect the health and safety of temporary workers they engage.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Occupational health assessment and training were ID Medical’s responsibility, while regulatory scrutiny belonged to the regulator and Crown Commercial Service.

Verbatim wording from the response

“Both contractually and legislatively the responsibility on ID Medical was to carry out an occupational health assessment and training. I can confirm Reed have seen evidence of this dating back to 2012 which falls in line with when Mr Nyeruke first engaged with ID Medical. However, Reed are unable to investigate the detailed evidence beyond the health clearance such as the medical declarations made by Mr Nyeruke, and other supporting evidence that underpin the occupational health fitness to work certificate, nor can we fully scrutinise the training content that sits behind the certificates. This is a matter for the regulator and Crown Commercial Service, which is why we escalated this matter to them within 24/76 hours of receiving your initial report.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 1 · response
Published 19 November 2020

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 the risk arising from agencies supplying vulnerable support workers rests with Reed agency.

Verbatim wording from the response

“We have considered the contents of your report very carefully and our response is set out below. We have not responded to point 3 as we believe this matter rests with the Reed agency.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 1 · response
Published 19 November 2020

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

Agency suppliers and workers are responsible for occupational-health screening and assessing placement risks before agency staff are assigned.

Verbatim wording from the response

“In response to point one, our investigations have established that all the suppliers of our bank and agency staff members are responsible for ensuring the occupational health screening of their workers is completed”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 1 · response
Published 19 November 2020

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 booking system cannot prevent vulnerable or high-risk workers from viewing shifts requiring general skills such as fit testing.

Verbatim wording from the response

“During our discussions we explored whether there was any way we could prevent high risk/vulnerable workers from viewing available shifts where a ‘general skill’ such as being fit tested or having IV drug competency is attached. We concluded that the system would not allow us to do this; however, all bank and agency staff assessed as being high risk or vulnerable have been advised to call Reed to check the status of a ward during Covid. All bank and agency staff classed as vulnerable or high risk have been advised to carry with them a copy of their risk assessment in case of any potential ward moves once their shift commences.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 3 · response
Published 19 November 2020

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Trust cannot require staff to disclose health information because there is generally no enforceable disclosure obligation, subject to limited exceptions.

Verbatim wording from the response

“in line with an agreed national framework. The results of this screening are not disclosed to the organisation where the bank or agency member of staff is placed. The Trust is therefore reliant on the agency or worker assessing the risk to the individual and other staff and patients prior to placement. It should be noted however there is no enforceable obligation on a member of staff be they bank, agency or a Trust employee to disclose information about their health. The exception to this would be where the condition poses a direct threat to the health of others, but even in these cases we are very much reliant on the member of staff’s openness despite the fact that the failure to disclose is a potential breach of Health and Safety legislation.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 2 · response
Published 19 November 2020

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Notify and brief relevant regulators and framework bodies about the matter.

    Stated by Reed Specialist Recruitment LimitedStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.
  2. 2

    Share the response letter with the Employment Agency Standards, Crown Commercial Service, Care Quality Commission and Leeds Teaching Hospital.

    Stated by Reed Specialist Recruitment LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 November 2020.
  3. 3

    Continue discussions with the Employment Agency Standards and Crown Commercial Service about a joint approach to improving supply-chain standards.

    Stated by Reed Specialist Recruitment LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
  4. 4

    Apply standard infection-control precautions, including hand hygiene and risk-assessed personal protective equipment, to reduce transmission risks.

    Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2020.

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

Notify and brief relevant regulators and framework bodies about the matter.

Verbatim wording from the response

“Both contractually and legislatively the responsibility on ID Medical was to carry out an occupational health assessment and training. I can confirm Reed have seen evidence of this dating back to 2012 which falls in line with when Mr Nyeruke first engaged with ID Medical. However, Reed are unable to investigate the detailed evidence beyond the health clearance such as the medical declarations made by Mr Nyeruke, and other supporting evidence that underpin the occupational health fitness to work certificate, nor can we fully scrutinise the training content that sits behind the certificates. This is a matter for the regulator and Crown Commercial Service, which is why we escalated this matter to them within 24/76 hours of receiving your initial report.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 1 · response
Published 19 November 2020

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

Share the response letter with the Employment Agency Standards, Crown Commercial Service, Care Quality Commission and Leeds Teaching Hospital.

Verbatim wording from the response

“I will share a copy of this letter with the EAS, CCS, CQC, and Leeds Teaching Hospital. I would also be very happy to engage any other bodies or organisations you see fit to work towards addressing any issues within modern supply chains.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Continue discussions with the Employment Agency Standards and Crown Commercial Service about a joint approach to improving supply-chain standards.

Verbatim wording from the response

“I fully appreciate the seriousness of this matter and therefore we had already taken the necessary steps to notify the Employment Agency Standards (EAS) as well as the NHS Framework Crown Commercial Service (CCS). Following your recent response, I have also personally explained the position to the Care Quality Commission (CQC) too. As Chair of the first cross-government and 3rd party organisation focusing on labour market and supply chain compliance and worker rights I am committed to ensuring the safety of non-permanent workers and identifying any weaknesses in modern supply chains. As such, I continue to talk to the EAS and CCS about this matter and how a joint, multi-agency approach could improve standards. To do this, it is important to understand the detail surrounding the occupational health assessments and training to understand what may have gone wrong.”

Source location

2020-0177-Response-from-Reed-Specialist-Recruitment-Ltd-Redacted.pdf
Page 2 · response
Published 19 November 2020

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

Apply standard infection-control precautions, including hand hygiene and risk-assessed personal protective equipment, to reduce transmission risks.

Verbatim wording from the response

“As a consequence, the Trust has a number of infection control measures in place aimed at mitigating the risk of cross infection. For example, there are standard precautions in place, (also known as universal precautions) which are intended to reduce the risk of transmission of blood borne and other pathogens from both recognised and unrecognised sources. They are the infection control precautions which are to be used, as a minimum, in the care of all patients. Hand hygiene is a major component of these standard precautions as is the wearing of personal protective equipment, the use of which is guided by risk assessment and the extent of contact anticipated with blood and bodily fluids, or pathogens.”

Source location

2020-0177-Response-from-Leeds-Teaching-Hospitals-NHS-Trust_Redacted.pdf
Page 2 · response
Published 19 November 2020

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026