Ineffective Staff Deployment
Failure to effectively deploy staff to meet service users' needs, coupled with unclear or inadequate training and induction records.
40 items
1 source
16 inquiries
Source spread
Where this theme appears
Ineffective Staff Deployment has been flagged across 1 independent accountability source:
40 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (40)
18 — Role of general practitioners
Recommendation: The employment of general practitioners should be rationalised to cover the day-to-day needs of long-stay patients: but their valuable contribution should not be regarded as a substitute for specialist services.
Unknown
37 — Protect clinicians' time for patient care
Recommendation: No clinician shall be asked to take on responsibilities that impair the ability to carry out patient care to the appropriate standard.
Unknown
121 — Limit interviews per interviewer per day
Recommendation: No more than two investigative interviews per interviewer per day should be undertaken and their workloads should be regularly monitored (17.61).
Unknown
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
41 — Control Room manning and qualification
Recommendation: The Control Room should at all times be in the charge of a person trained and qualified to undertake the work of Control Room operator. The Control Room should be manned at all times (para 18.35).
Unknown
75 — Mental health awareness training evaluation
Recommendation: The responses of those members of staff who have attended the mental health awareness training course should be analysed to determine whether the course can be improved. The number of front line staff attending the course should be increased, resources …
Unknown
66 — Assigning personal officers to prisoners
Recommendation: Personal officers should be assigned to individual prisoners, not to a group of cells. They should be members of a small team, so that when a prisoner’s personal officer is not on duty, the prisoner can approach another member of …
Unknown
65 — Mandatory personal officer schemes
Recommendation: It should be mandatory for all establishments to have a personal officer scheme. That includes busy local prisons, although if time for personal officer work is limited, it should be used constructively.
Unknown
R69 — Needs-based staffing with acuity measures
Recommendation: Staffing should be based on service user needs rather than a fixed budget, using daily acuity measures designed specifically for units caring for people with learning disabilities. These should include enhanced supervision requirements, personal care support and therapeutic activities. Service …
No response yet
25 — GWT to monitor maintenance staff workload
Recommendation: GWT should regularly monitor the workload of all maintenance staff (para 15.6).
Unknown
34 — Control overtime
Recommendation: Overtime worked by building and other staff should be more strictly controlled.
Unknown
24 — Separate domestic and nursing duties
Recommendation: Domestic duties should, so far as possible, be separated from nursing duties and a special programme started for recruiting and training domestic workers.
Unknown
10 — At least four new consultant psychiatrists
Recommendation: At least four new consultant psychiatrists should be appointed to Whittingham Hospital, with appropriate junior staff, and in making appointments the special needs of long-stay psychiatric and geriatric patients should be borne in mind. There will need to be an …
Unknown
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
R9 — Integrated workforce plans
Recommendation: Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in patient care. This should be based upon the assessed needs of the service user and must include protected …
No response yet
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.
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
ETI-3 — Staffing Guidance
Recommendation: The guidance mentioned in the first recommendation should include: advice concerning the circumstances in which civil servants in the inquiry team may properly transfer to posts, other than promoted posts, within other government departments or agencies; which positions within the …
Words of: Màiri McAllan, Cabinet Secretary for Transport, Net Zero and Just Transition, statement to the Scottish Parliament, 2 November 2023 (text as published by the Scottish Government)
Gov response: We are working through all of these recommendations, but I can report that additional guidance similar to that suggested is already in development with reference to the efficient establishment and delivery of public inquiries and …
Response Unclear
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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
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-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-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
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
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 and dependency in the ward. Where the clinical profile of …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
No update 2+ yrs
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. Any such decision should be based on a full …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
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 for the success of the project and the maintenance of patient safety throughout …
Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
ETI-19 — Collaborative Delivery
Recommendation: At all stages of the project there should be a collaborative approach to delivering it. This should include the co-location of representatives from each organisation relevant to the particular stage reached and having an interest in its completion to enable …
Words of: Andrew Kerr, Chief Executive, City of Edinburgh Council, report "Response to the Edinburgh Tram Inquiry" to the Council, 14 December 2023 (item 7.1)
Gov response: The Inquiry Report describes some of the damaging behaviours adopted during project delivery by various parties. The advantage of co locating representatives having an interest in project completion is understood and indeed was successfully adopted …
Accepted
ETI-18 — Interviews of Key Personnel in Readiness Reviews
Recommendation: As part of their investigations, representatives of OGC undertaking an independent “readiness review” of a publicly funded project and representatives of any person, including representatives of any public body such as Audit Scotland, undertaking a review of the progress of …
Words of: Andrew Kerr, Chief Executive, City of Edinburgh Council, report "Response to the Edinburgh Tram Inquiry" to the Council, 14 December 2023 (item 7.1)
Gov response: While this Recommendation is for third parties who may undertake a readiness review or audit of a publicly funded project in future, it is recommended that the Council agrees to support any such review or …
Noted
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 …
Words of: Northern Ireland Executive, Executive Response to the RHI Inquiry Report Recommendations and Action Plan, Annex A, 7 October 2021
Gov response: These recommendations can be accepted in full. They have been addressed through work to date, including: • job-specific appointments within the NICS generalist grades; • the piloting of Cabinet Office’s “Commercial Skills Assessment and Development …
Accepted
No update 2+ yrs
BAHA-41 — Detention Sergeant Role
Recommendation: On operations where CPERS may be taken there should be a Senior Non-Commisioned 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 …
Words of: Liam Fox, Secretary of State for Defence, statement to the House of Commons, 8 September 2011 (HC Deb vol 532 col 571), as published by the Ministry of Defence
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
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 that Military Annual Training Test …
Words of: Liam Fox, Secretary of State for Defence, statement to the House of Commons, 8 September 2011 (HC Deb vol 532 col 571), as published by the Ministry of Defence
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
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.
Words of: Chris Haward, NPCC Lead for Surveillance, in a letter to Abigail Scholefield, Fieldfisher, solicitors to the Inquiry, 20 October 2022
Gov response: The previous MOG and MOS do have relevant sections in relation to this recommendation but, again, have been strengthened as shown here: Covert Audio Intrusive Surveillance & Covert Monitoring Posts Staffing (Extract) Where a CMP …
Noted
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown