Unqualified Staff Deployment
Deployment of insufficient numbers of suitably qualified, competent, skilled, and experienced staff, failing to meet fundamental standards.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Terence Bennett
The report identifies inadequacies in care, risk, and crisis management plans, insufficient staff knowledge of medical records, and a lack of family involvement. Further concerns include reliance on unqualified staff, insufficient supervision, and poor multi-disciplinary working and handovers.
Matched on
terms: staff, unqualified
PFD report
73match
James Stewart
A lack of a system for new GP practices to verify medication details for nursing home patients led to critical omissions. The coroner also noted concerns regarding unqualified staff confirming prescriptions, highlighting the need for a robust system from the Clinical Commissioning Group.
Matched on
terms: staff, unqualified
CQC action
71match
The County Hospital
The provider must ensure it has sufficient numbers of suitably qualified, competent, skilled and experienced staff who receive such appropriate training to carry out the duties they are employed to perform and ensure staff are trained to the right competency in safeguarding and life support. The provider must have sufficient medical staff to run the department safely and...
Matched on
terms: staff
CQC action
71match
Durham Diagnostics and Treatment Centre
The service must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance.
Matched on
terms: staff
CQC action
71match
Clifton Hospital
The trust must ensure they deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Matched on
terms: staff
CQC action
66match
Broomfield Hospital
The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff.
Matched on
terms: staff
CQC action
66match
St Benedict's Hospice
The service should continue to ensure that there are sufficient numbers suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients dependency levels.
Matched on
terms: staff
Committee recommendation
66match
#43 - Review children's home staff qualifications and introduce minimum standards for residential childcare workers.
The Department should use its children’s home workforce census to review the levels of qualifications currently held by residential staff. It should also consult on introducing minimum qualification standards for residential childcare workers and work with local authorities to assess what initial action can be taken to upskill the existing workforce. (Recommendation, Paragraph 100)
Matched on
terms: staff
PFD report
65match
John Leyin
The coroner identified gaps in the dissemination of Trust policy and NPSA guidance, weaknesses in staff training and checking for current competency in procedures. There was also insufficient knowledge regarding the number of trained staff available for such tasks.
Matched on
terms: staff
CQC action
64match
Westmorland General Hospital
The service must ensure they deploy sufficient suitably competent and experienced staff and ensure all staff receive appropriate skills and drills training and professional development to enable them to maintain competency given the low numbers of deliveries.
Matched on
terms: staff
CQC action
64match
Kettering General Hospital
The servicemust ensure there are sufficient numbers of suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs. This includes medical, registered nursing and non-registered nursing staff.
Matched on
terms: staff
PFD report
61match
Albert Flynn
Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Matched on
terms: staff
PFD report
61match
George Marks
Agency staff demonstrated insufficient understanding of hospital policies and procedures for medication administration, record-keeping on prescription charts and nursing notes, and correct patient handover procedures.
Matched on
terms: staff
PFD report
61match
Alison Evers
The coroner identified a lack of written policy for 'no treats' and insufficient first aid training for health support workers. There was also no policy ensuring a first aid trained member of staff on every shift.
Matched on
terms: staff
PFD report
61match
Simon Graham
The coroner noted that lone working arrangements delayed emergency response and CPR, exacerbated by incorrectly labelled keys. Unqualified support workers conducted suicide risk assessments without adequate guidance or training.
Matched on
terms: unqualified
PFD report
61match
Robert Rostron
The coroner raised concerns regarding HC One's use of agency nurses who lack unit-specific induction, knowledge of policies, or patient care plans, especially when they are the only qualified staff or lead shifts.
Matched on
terms: staff
PFD report
61match
Rodney Gates
The coroner raised concerns regarding the failure to undertake required patient observations, which was linked to low nursing staff numbers, reliance on agency nurses, and a lack of staff experience and equipment on the ward.
Matched on
terms: staff
PFD report
61match
Adam Brunskill
The coroner identified that the employee worked on a roof without prior experience or mandatory safety training. There was an absence of designated supervision and a structured training programme for new or unqualified employees.
Matched on
terms: unqualified
PFD report
61match
Maria Howell
The care home lacked qualified nursing staff to reinsert a time-critical RIG tube for a resident with complex needs. Concerns were also raised about staff clinical judgment regarding critically ill patients who required urgent medical attention.
Matched on
terms: staff
PFD report
61match
Michael Smith
Insufficient staff on duty in the SACU meant medical assessments were not undertaken for the deceased. A single officer on duty also caused a delay in emergency response due to the three-man unlock requirement.
Matched on
terms: staff
CQC action
61match
Saint Mary's Hospital
The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)
Matched on
terms: staff
CQC action
61match
Chorley and South Ribble Hospital
The service should ensure the maternity assessment service has the right number of qualified staff and the triage telephone line is answered and monitored by a trained midwife.
Matched on
terms: staff
CQC action
59match
The Tunbridge Wells Hospital at Pembury
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for women, birthing people and babies.
Matched on
classifier match
CQC action
59match
Ambulance Headquarters, Bernicia House
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
Matched on
classifier match
PFD report
57match
Elsie Mallalieu
The patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Matched on
terms: staff
PFD report
57match
Peter Wright
The coroner identified concerns regarding significant ward understaffing, which led to one nurse caring for 16 patients and performing a drug round alone. Additionally, the report noted a lack of out-of-hours doctor cover at St George's Hospital.
Matched on
terms: staff
PFD report
57match
Dorothy McDermott
The coroner noted the inappropriate placement of a vulnerable individual in a residential care home that lacked nursing care and pressure sore training for staff. There was concern that availability was prioritised over the suitability of the placement, and formal guidance is needed for agencies.
Matched on
terms: staff
PFD report
57match
Ratidzai Sangare
Healthcare staff did not recognise Mrs Sangare's need for immediate cardiopulmonary resuscitation, and did not respond immediately to an activated alarm, assuming it was a behavioural issue. There was also limited telephone access for agency staff.
Matched on
terms: staff
PFD report
57match
Patrick Curran
The coroner identified a practice where nursing staff conducted first post-operative reviews and discharges without adequate medical oversight, leading to a patient presenting unwell not being seen by a doctor.
Matched on
terms: staff
PFD report
57match
Frederick Chisnall
The coroner raised concerns regarding agency staff's documentation practices and their awareness of monitoring clinical changes and urgently seeking medical or nursing help.
Matched on
terms: staff
PFD report
57match
Reginald Lewis
The patient was left unsupervised without staff awareness, and ward C19 was already stretched with high-dependency patients, leading to junior staff feeling pressured to accept the patient despite reservations about capacity.
Matched on
terms: staff
PFD report
57match
Daniel Stokes
The coroner noted the jury's view that proper systems were lacking for prison healthcare staff to be trained and authorised to administer diazepam when a prisoner is suffering from controlled drug abuse.
Matched on
terms: staff
PFD report
57match
Mildred Clark
The coroner raised concerns that an untrained paramedic was instructed by a hospital doctor via telephone to reduce a suspected hernia, a procedure beyond their role and potentially dangerous if strangulated. There was also concern about staff feeling pressured to avoid hospital admissions.
Matched on
terms: staff
PFD report
57match
Emma Dorman
Non-clinical staff significantly influenced decisions regarding patient leave, leading clinical staff to feel unable to object. There was also a persistent lack of psychologist input on the ward for over three years.
Matched on
terms: staff
PFD report
57match
David Martin
The coroner noted inadequate induction for a long-term locum doctor regarding specific cardiology policies. There were also missed opportunities to identify incorrect patient medication, even after the oversight was recognised by staff.
Matched on
terms: staff
PFD report
57match
Christiana Dawson
The coroner noted a clear risk of future deaths if agency staff at Darnell Grange are not provided with home-specific training or policies, specifically regarding the protocol for moving residents after a fall.
Matched on
terms: staff
HSSIB recommendation
57match
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that inductions are carried out and that the time needed to complete local inductions is factored into the workload of staff?
Matched on
terms: staff
CQC action
57match
Royal Berkshire Hospital
The service should continue to review the management of recovery care to ensure this is provided by appropriately trained and competent staff.
Matched on
terms: staff
PFD report
53match
Willow Davies
The coroner noted insufficient support for a newly qualified midwife assisting with a delivery and that midwife allocation did not consider individual experience. The 'Supervisors of Midwives' system at Bedford Hospital required urgent review.
Matched on
classifier match
PFD report
53match
Joan Coley
The coroner identified insufficient training for medical students and junior doctors in taking bloods from central lines, coupled with a lack of formal competency assessment, standard operating procedures, and a system for handing over skills between wards.
Matched on
classifier match
Committee recommendation
53match
#35 - 2nd Report - Lost in translation? Interpreting services in the courts
The Government should set out a clear plan to ensure that all interpreters in the courts are qualified up to a level 6 standard wherever this qualification is available in a language, or an alternative appropriate qualification for rarer languages where there is not a formal qualification. The plan should include time-bound milestones and steps to develop qualifications...
Matched on
classifier match
HSSIB recommendation
53match
Placement of nasogastric tubes
The Trust where the reference event happened implemented and recorded training and competency assessments for all nursing staff prior to allowing them to insert and confirm placement of nasogastric tubes.
Matched on
terms: staff
CQC action
53match
The York Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Matched on
terms: staff
CQC action
53match
Scarborough Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Matched on
terms: staff
CQC action
53match
Royal Sussex County Hospital
The trust must ensure that staff in theatres are supported to work within their clinical competency and that there are suitable arrangements for monitoring this.
Matched on
terms: staff
CQC action
53match
Doncaster Royal Infirmary
The trust must ensure they have enough staff with the right qualifications, skills, training, and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Matched on
terms: staff
CQC action
53match
Oakwood
The provider must ensure people are supported by staff with the required knowledge and skill and that staff receive the training and support required to support them in their roles.
Matched on
terms: staff
CQC action
53match
St Helier Hospital and Queen Mary's Hospital for Children
The service must ensure the role of recovery practitioner is role is carried out by staff with the right level of qualification and additional training.
Matched on
terms: staff
CQC action
53match
Stamford & Rutland Hospital
The service should ensure that staff providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Matched on
terms: staff
CQC action
53match
Epsom General Hospital
The service must ensure the role of recovery practitioner is carried out by staff with the right level of qualification and additional training.
Matched on
terms: staff