PFD report

Mrs Kathleen Booth · Prevention of Future Deaths report

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Issued 22 Nov 2023•Staffordshire and Stoke-on-Trent

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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 raised3

  1. Failure to maintain sufficient staffing and funding capacity for timely surgery
    Part of recurring concern: Insufficient clinical staffing capacity for timely surgical carePart of recurring concern: Insufficient qualified healthcare staffing capacity
  2. Failure to ensure adequate and experienced staffing for Friday injuries
    Part of recurring concern: Insufficient clinical staffing capacity for timely surgical care
  3. Limited weekend clinical cover for injuries sustained on Fridays
    Part of recurring concern: Insufficient medical staffing capacity for timely patient carePart of recurring concern: Insufficient safe staffing and senior cover out of hours
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.8

  1. Action

    Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2023.
  2. Action

    Increase elective care capacity, prioritise diagnosis and treatment, transform care delivery, and improve patient information and support.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2023.
  3. Action

    Increase urgent and emergency care capacity, including funding additional capacity and 5,000 new beds.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Staffordshire and Stoke-on-Trent Integrated Care System is responsible for local urgent and emergency care workforce arrangements.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 maintain sufficient staffing and funding capacity for timely surgery

Wider context from the report

“1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time. Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available. ”

Is this part of a recurring concern?

Yes — Insufficient clinical staffing capacity for timely surgical care; Insufficient qualified healthcare staffing capacity.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure adequate and experienced staffing for Friday injuries

Wider context from the report

“1. There was a 4 day delay in her receiving surgery due to NHS wide under staffing and underfunding; and wards having to undertake elective and emergency work at the same time. Additionally, the fact that the injury happened on a Friday, meaning less staff and experience was available. ”

Is this part of a recurring concern?

Yes — Insufficient clinical staffing capacity for timely surgical care.

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

Limited weekend clinical cover for injuries sustained on Fridays

Wider context from the report

“3. Patients can be disadvantaged by not receiving treatment if an injury is sustained on a Friday as cover over the weekend is limited. ”

Is this part of a recurring concern?

Yes — Insufficient medical staffing capacity for timely patient care; Insufficient safe staffing and senior cover out of hours.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop local workforce planning and distribute future training posts to match doctors’ supply with population need.

Verbatim wording from the response

“The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.”

Source location

Response from NHS England
Page 2 · response
Published 28 November 2023

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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

Increase elective care capacity, prioritise diagnosis and treatment, transform care delivery, and improve patient information and support.

Verbatim wording from the response

“Elective care recovery also continues to be a priority for the NHS. In February 2023 the Delivery plan for tackling the Covid-19 backlog of elective care was published by NHS England. This focused on four areas of delivery to increase health service capacity, prioritise diagnosis and treatment, transform how we provide elective care and provide better information and support to patients. This is supported by a government spend of more than £8 billion between 2022/23 and 2024/25, including a £5.9 billion capital investment in new beds, equipment, and technology. Further priorities were set out in a letter to NHS acute Trusts in May 2023, which can be found here: NHS England » Elective care 2023/24 priorities.”

Source location

Response from NHS England
Page 2 · response
Published 28 November 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

Increase urgent and emergency care capacity, including funding additional capacity and 5,000 new beds.

Verbatim wording from the response

“In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:”

Source location

Response from NHS England
Page 1 · response
Published 28 November 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

Grow the urgent and emergency care workforce, including introducing more flexible ways of working.

Verbatim wording from the response

“In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:”

Source location

Response from NHS England
Page 1 · response
Published 28 November 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

Implement seven-day clinical standards and require acute trusts to provide board assurance of compliance.

Verbatim wording from the response

“In 2013, NHS England published its 7-Day Hospital Services (7DS) Programme which introduced clinical standards regarding the provision of a “truly seven-day NHS” and requiring acute trusts to provide board assurance of compliance. The Programme focuses on the provision of acute medical care in such a way that there is no difference in quality for patients, whether it is a weekday or a weekend. There is a good level of compliance with these standards across acute trusts and many services and surgical and diagnostic lists are operating at weekends and evenings.”

Source location

Response from NHS England
Page 1 · response
Published 28 November 2023

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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

Train, retain and reform the NHS workforce through the Long Term Workforce Plan.

Verbatim wording from the response

“In June 2023, NHS England also published the NHS Long Term Workforce Plan, setting out how it will train, retain and reform its workforce across the next fifteen years”

Source location

Response from NHS England
Page 1 · response
Published 28 November 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

Operate a dedicated fragility-fracture theatre list five days per week.

Verbatim wording from the response

“However, the trust does annually review capacity and demand for all its services and based on one of these reviews and subsequent business case, on the 6 November 2023, the Trauma Directorate introduced a dedicated fragility fracture list, 5 days per week. This has seen a reduction in time to theatre for this cohort of patients since its inception. Capacity and demand also include the weekend provision and the division are preparing a business case to see if the demand over the weekend period requires the same on a Saturday also.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 28 November 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

Review weekend demand and prepare a business case for extending dedicated fragility-fracture theatre capacity to Saturdays.

Verbatim wording from the response

“However, the trust does annually review capacity and demand for all its services and based on one of these reviews and subsequent business case, on the 6 November 2023, the Trauma Directorate introduced a dedicated fragility fracture list, 5 days per week. This has seen a reduction in time to theatre for this cohort of patients since its inception. Capacity and demand also include the weekend provision and the division are preparing a business case to see if the demand over the weekend period requires the same on a Saturday also.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 28 November 2023

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

Staffordshire and Stoke-on-Trent Integrated Care System is responsible for local urgent and emergency care workforce arrangements.

Verbatim wording from the response

“The NHS continues to encourage local health systems to develop effective workforce planning to ensure that they have the sufficient qualified staff working across their Trusts and wider system that are required for their population care needs. The NHS People Promise also helps NHS providers to consider ways to recruit and retain staff. Work is in progress to ensure that future distribution of training posts to help ensure the supply of doctors is matched to population need. You will need to refer to Staffordshire and Stoke-on-Trent Integrated Care System on what system arrangements they have in place for their UEC provision and workforce.”

Source location

Response from NHS England
Page 2 · response
Published 28 November 2023

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

A dedicated weekend fragility-fracture theatre depends on available clinical and financial resources.

Verbatim wording from the response

“The trust is also reviewing whether there is a need for a dedicated fragility fracture theatre over the weekend. As referenced in the response to question 2, this is a matter which is being reviewed and will be dependent on available clinical and financial resources.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 3 · response
Published 28 November 2023

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

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 November 2023.
  2. 2

    Speed up discharge from hospitals to improve urgent and emergency care flow.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.
  3. 3

    Help patients access the right care first time within urgent and emergency care services.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.
  4. 4

    Expand community services to help avoid emergency admissions.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    National Hip Fracture Database data does not link theatre delay with increased mortality risk.

    Stated by University Hospitals of North Midlands NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 28 November 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

Speed up discharge from hospitals to improve urgent and emergency care flow.

Verbatim wording from the response

“In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:”

Source location

Response from NHS England
Page 1 · response
Published 28 November 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

Help patients access the right care first time within urgent and emergency care services.

Verbatim wording from the response

“In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:”

Source location

Response from NHS England
Page 1 · response
Published 28 November 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

Expand community services to help avoid emergency admissions.

Verbatim wording from the response

“In January 2023, NHS England published the Delivery plan for recovering urgent and emergency care services. This is a two-year delivery plan which sets the NHS commitment to the public to improve waiting times and patient experience within urgent and emergency care (UEC). This includes commitments to:”

Source location

Response from NHS England
Page 1 · response
Published 28 November 2023

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

National Hip Fracture Database data does not link theatre delay with increased mortality risk.

Verbatim wording from the response

“2. It is agreed that earlier intervention is associated with better outcomes for patients requiring emergency (and urgent) surgery following injury. As a Trust with a significant major trauma unit, we endeavour to treat patients with a fragility fracture within 36 hours of presentation where clinically appropriate. However, the data within the NHFD (National Hip Fracture Database) does not link a delay in theatre with an increased risk of mortality.”

Source location

Response from University Hospitals of North Midlands NHS Trust
Page 2 · response
Published 28 November 2023

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