Ineffective Staff Deployment
47 items
2 sources
Failure to effectively deploy staff to meet service users' needs, coupled with unclear or inadequate training and induction records.
Cross-Source Insight
Ineffective Staff Deployment has been flagged across 2 independent accountability sources:
26 inquiry recs
21 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (26)
BAHA-40 — Battlegroup Detention Officer
Recommendation: Each Battlegroup should have a 'Detention Officer' being a commissioned officer within Battlegroup Headquarters. The role should encompass coordination and management of CPErS; acting as a focus on CPErS matters during mission specific training; ensuring correct handling of CPErS; assisting …
Gov response: Accepted. The role of Battlegroup Detention Officer has been established.
Accepted
Delivered
BAHA-41 — Detention Sergeant Role
Recommendation: On operations where CPErS may be taken there should be a Senior Non-Commissioned Officer (NCO) who acts as the 'Detention Sergeant' who has responsibility for the administrative aspects of CPErS handling. In most cases, it would be appropriate for the …
Gov response: Accepted. The Detention Sergeant role has been established for operations involving CPErS.
Accepted
Delivered
ETI-18 — Effective Communication and Reporting
Recommendation: There should be effective communication and reporting at all stages of the project, including accurate progress reports to councillors and stakeholders, with clear escalation procedures for issues that may affect cost, programme or scope.
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it, including co-location of representatives from each organisation relevant to the particular stage, enabling issues to be addressed and resolved at the earliest opportunity, minimising risk …
Gov response: Council Leader Cammy Day stated: 'We know that serious mistakes were made in the construction of the original tram line.' The Council broadly agrees with Lord Hardie's recommendations but notes improvements were already implemented for …
Accepted
No update 2+ yrs
ETI-3 — Staffing Guidance
Recommendation: Guidance should address: circumstances for civil servant transfers within government; which positions may use agency staff; and whether temporary contracts suit positions unfillable by permanent staff.
Gov response: The Scottish Government stated that guidance similar to that suggested is already in development. Source: Transport Secretary Statement, 2 November 2023.
Accepted in Part
No update 2+ yrs
FENN-80 — Ensure adequate staffing by suitably trained personnel in station operations rooms
Recommendation: Station operations rooms shall always be adequately staffed by suitably trained personnel.
Unknown
FENN-91 — Appoint and train station 'landlords' with total management responsibility
Recommendation: A station 'landlord' shall be appointed and trained to have total management responsibility at each major station or group of smaller stations.
Unknown
FENN-92 — Appoint only qualified relief supervisory staff to stations
Recommendation: Relief supervisory staff shall only be appointed to a station for which they are qualified.
Unknown
FENN-96 — Allocate physically suitable staff to roles, ensuring station safety balance
Recommendation: London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Unknown
FLIX-210 (i) — Exercise special care when making decisions during important post vacancies
Recommendation: That when an important post is vacant special care should be exercised when decisions have to be taken which would normally be taken by or on the advice of the holder of the vacant post. This, in the present instance, …
Unknown
JB-15.14 — Require trained CMP manager for covert monitoring posts
Recommendation: CMPs should not be established without the appointment of a properly trained CMP manager, whose responsibility it should be to appoint a team of CMOs, once satisfied from proper assessment as to their qualifications and ability.
Gov response: MPS formally responded on 28 October 2022 (paras 24-25). Guidance issued reaffirming Surveillance MoS 2021 position: only trained officers may perform CMP roles; no CMP without accredited CMP Manager.
Accepted
Delivered
MAI-10 — Resolve paramedic-driver shortage in mass casualties
Recommendation: A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-6 — Ensure Airwave Tactical Advisors availability
Recommendation: All police services should ensure that they have made adequate provision for Airwave Tactical Advisors, in particular that an identified Airwave Tactical Advisor is either on duty or on call at all times.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-72 — Review NWAS Tactical Advisor rostering coverage
Recommendation: North West Ambulance Service should review how it rosters Tactical Advisors and National Interagency Liaison Officers so as to ensure that there is adequate geographical coverage enabling those on duty to arrive promptly at the scene of any Major Incident.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-76 — Review HART mobilisation policies
Recommendation: North West Ambulance Service should review its policies for mobilising the Hazardous Area Response Team resource, to ensure that this team is available as soon as possible for an emergency where its specialist skills are required.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-82 — Allocate best-trained operators to Major Incident roles
Recommendation: North West Fire Control should review how it allocates the best-trained and most suitable Control Room Operators to roles during a Major Incident. It should consider whether it is beneficial to allocate a Control Room Operator to monitor communications on …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-93 — 24-hour qualified command structure rostering
Recommendation: The College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should ensure that each police service has in place a system that means appropriately qualified and experienced personnel are rostered 24 hours each day so …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
14 — Review clinical leadership arrangements
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
5 — Promote effective multidisciplinary team-working
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and develop measures that will promote effective multidisciplinary team-working, in particular between paediatricians, obstetricians, midwives and neonatal staff. These measures should include, but not be limited to, joint training …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
9 — Improve joint working between hospital sites
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify an approach to developing better joint working between its main hospital sites, including the development and operation of common policies, systems and standards. Whilst we do not believe that …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
RHI-24 — Staff Move Sequencing
Recommendation: Senior managers in the Civil Service must take responsibility for guiding and, where necessary, sequencing the timing of staff moves so that continuity of business is secured. This includes allowing sufficient time for transferring staff to hand over, and discuss …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
No update 2+ yrs
R13 — Clear nursing responsibility line
Recommendation: Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
Gov response: Section 2.2 of the Scottish Government's response addresses leadership and management structures. It highlights the strengthened role of senior charge nurses through the Leading Better Care initiative, which provides a template for developing their role …
Accepted
R17 — Ward admission responsibility
Recommendation: Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICP) which are basic infection prevention and control measures. One of the ten SICPs is "Patient placement in wards and bays," directly …
Accepted
R31 — Staffing and skills mix review
Recommendation: Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity.
Gov response: Section 4.1 of the Scottish Government's response details the development and mandatory use of ground-breaking nursing and midwifery workload and workforce planning tools across all NHS boards. These tools help determine the number of nurses …
Accepted
R8 — Reorganisation management structure
Recommendation: In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place.
Gov response: Section 2.2 of the Scottish Government's response emphasizes that leaders and managers at all levels are responsible for quality of care and that investment is needed in leadership and management. Work is ongoing locally and …
Accepted
PFD Reports (21)
Lindy Aston
Concerns: A critically ill patient requiring urgent splenectomy was not operated on at Kettering General Hospital, despite the capability, resulting in a 24-hour delay and transfer that likely contributed to her death.
Responded
Patricia Walton
Concerns: Insufficient medical cover over a bank holiday period meant no doctor assessed the patient for four days, highlighting a lack of attention to subtle care needs beyond emergencies.
Responded
Roy Walklet
Concerns: Hospital policy prevented a crucial gastroscopy until a ward bed was available. A consultant was also unaware of patient allocation because the patient remained in A&E, delaying critical review.
Overdue
Charlotte Comer
Concerns: The Trust suffered from severe understaffing, leading to excessive care coordinator caseloads and fragmented patient care. A senior clinician unilaterally overrode a Multi-Disciplinary Team decision, highlighting a lack of robust procedural oversight.
Responded
Benjamin Stroud
Concerns: A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
Overdue
Jack Taylor
Concerns: Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Responded
Rebecca Pykett
Concerns: The Community Mental Health Team failed to properly allocate and ensure Care Co-Ordinators fulfilled their roles, leading to inadequate patient care and missing care plans.
Responded
Henry Holcombe
Concerns: The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Responded
Lesley Mawby
Concerns: Persistent staffing shortages in the dietetic team lead to delayed patient assessments on weekdays and a complete lack of weekend service.
Responded
James Francis
Concerns: Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.
Responded
Faye Allen
Concerns: Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline first aiders, significantly reducing actual direct medical provision.
Overdue
Sharon Grierson
Concerns: There was a lack of appreciation for capnography readings, poor coordination, and senior staff lacked experience in crisis situations, highlighting a need for better training in emergency management.
Responded
Kathryn Richmond
Concerns: The ambulance service's non-staggered shifts meant multiple ambulances were unavailable for calls during simultaneous meal breaks, critically reducing resources and delaying emergency response.
Overdue
Errol Mann
Concerns: The Intensive Care Unit experienced severe and persistent staffing shortages, including Clinical Fellows, which directly compromised patient care and diverted consultant time from clinical duties.
Overdue
Jamie Fairclough
Concerns: Excessively high caseloads for Care Co-ordinators, often exceeding 75-80 service-users, compromised the quality of patient care and staff's ability to manage their responsibilities.
Overdue
Jasmine Lapsley
Concerns: Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource planning for seasonal population increases.
Responded
Ethan Johnson
Concerns: There was a critical lack of leadership and support for junior staff managing an abnormal CTG trace, compounded by a hierarchical system preventing timely consultant attendance.
Responded
Blaise Farry
Concerns: Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.
Overdue
Olive Nugent
Concerns: Falls activator device responses were delayed due to subjective prioritisation and insufficient staffing, particularly for non-verbal users, leaving vulnerable individuals without timely assistance.
Overdue
Henry Marsh
Concerns: The Home Treatment Team was overloaded with excessive patient caseloads, hindering effective multi-disciplinary meetings and compromising patient care.
Responded
Keith Samuel Peters
Concerns: Inefficient case allocation and lack of prioritisation for assessments, combined with no system to reallocate cases when officers cannot meet deadlines, caused significant delays.
Response: Bolton Council has cascaded lessons learned throughout the organisation and implemented measures to improve systems, processes, and officer training. They will also oversee the full implementation of an enclosed action …
Responded