Staff rota communication
98 items
2 sources
Failures in communicating staff rota changes directly to staff members, relying solely on electronic system updates.
Cross-Source Insight
Staff rota communication has been flagged across 2 independent accountability sources:
4 inquiry recs
94 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (4)
IHRD-18 — On-Call Consultant Display
Recommendation: The names of all on-call consultants should be prominently displayed in children's wards.
Gov response: On-call consultant information displayed in children's wards.
Accepted
Delivered
LADB-12 — Increase driver briefing frequency with safety as primary agenda item
Recommendation: Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and …
Unknown
LADB-46 — Establish and apply criteria for signallers exceeding maximum 72-hour work week
Recommendation: Railtrack management should set out the criteria for allowing signallers, in exceptional circumstances, to exceed the maximum of 72 hours of work per week, and ensure that these criteria are, and continue to be, correctly applied (para 12.19).
Unknown
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: Section 4.1 of the Scottish Government's response discusses general workforce planning, including the use of nursing and midwifery workload and workforce planning tools to determine the number of nurses or midwives needed. However, the provided …
Accepted
PFD Reports (94)
James Fitzpatrick
Concerns: A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient care.
Pending
Joan Read Prevention of future deaths report
Concerns: A single consultant lacking cross-cover for geriatric perioperative care creates a risk of urgent test results being missed during periods of absence.
Pending
Margaret Crooks
Concerns: Confusion among stroke clinicians about the level of overnight expert support available led to delays in time-critical advice for stroke complications, potentially affecting patient outcomes.
Response: Greater Manchester Integrated Care has reviewed its Comprehensive Stroke Centre service specification and Standard Operating Procedure. Following this, the network plans to add further detail to the SOP to clarify …
Responded
Mark Townsend
Concerns: Stewards' lack of awareness regarding the nearest radio location caused delays in summoning medical assistance, posing a future risk for timely emergency response.
Response: Sheffield Wednesday Football Club disputes that the brief delay in radio communication indicates an unsafe system, noting the inquest found no causative failings. They state they will continue existing measures …
Responded
Victor Hutchens
Concerns: Care rounds were erroneously reduced from hourly to four-hourly, and the staff member responsible couldn't explain how the error occurred, raising concerns about potential recurrence.
Responded
Simon Moore
Concerns: A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.
Responded
Azroy Dawes-Clarke
Concerns: Communication during a medical emergency in prison was confused, with no clear command structure established between prison staff, healthcare, and paramedics, indicating an ongoing risk for future critical events.
Overdue
Denise Johnson
Concerns: The hospital had insufficient timely feedback for practitioners on ERCP complications, poor communication with families, and unclear consultant cover for unexpected leave, compromising patient safety.
Responded
Alfie Hinton
Concerns: Inadequate assessment and communication of maternal risks led to delays in monitoring and expediting delivery. Poor communication and absence of policy between consultants during a time-critical spinal anaesthetic procedure also caused significant delays.
Responded
Charlotte Roscoe
Concerns: Confusion exists about appropriate scan types for pulmonary embolism and the need for clinicians to consult radiologists for specific requests. This issue, not fully addressed in an After Action Report, risks future diagnostic errors.
Responded
Rachael Ryan
Concerns: The absence of a clear protocol for deep tissue biopsy and failure to hold a multi-disciplinary meeting led to significant delays in diagnosis and appropriate antibiotic treatment.
Responded
Gabrielle Steel
Concerns: Critical fire safety assessment findings were not communicated by the London Fire Brigade to carers or family, preventing the implementation of a vital risk management plan for a vulnerable individual.
Responded
Miriam Stone
Concerns: Mental health unit admissions during staff handovers led to confusion over task allocation and risk assessment responsibility, exacerbated by the lack of a formal policy to manage or avoid admissions at these times.
Responded
Iain Hughes
Concerns: Unclear protocols regarding decision-making authority and communication of concerns for aborting a swim during a channel crossing can lead to unnecessary delays and increased risk.
Responded
Jennifer Trigger
Concerns: A miscommunication due to an inadequate bleep system caused critical delays in administering medication, leading to patient deterioration. The system's inability to electronically convey information risked proper task prioritization.
Responded
Paul Bradley
Concerns: Systemic failures in patient follow-up, appointment tracking, and inter-team communication led to missed critical appointments and inadequate care for a hard-of-hearing patient.
Responded
Claire Homer
Concerns: The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Responded
Jason Bayley
Concerns: Repeated incorrect documentation of medication adherence in patient records, despite patient refusal, created a breakdown in communication and posed a risk of harm due to misunderstanding actual medication intake.
Responded
Jonathan Mann and Margaret Costa
Concerns: Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.
Overdue
Jessica Hodgkinson
Concerns: Critical medication (tinzaparin) was discontinued due to poor communication between hospital trusts during transfer and discharge, and Chesterfield failed to follow up on the patient's care. Additionally, the potential impact of KTS on pregnancy was not adequately considered or documented by consultants.
Overdue
Bonnie Webster
Concerns: Parents were inadequately informed of the baby's serious condition, antibiotics were significantly delayed, and staff used an inefficient, non-emergency method to alert the paediatric team.
Responded
Joan Rossington
Concerns: External care staff supporting the patient on the ward were excluded from risk assessments and care plans, leading to potential delivery of conflicting care and an unsafe environment.
Overdue
Shahan Aman
Concerns: Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an inappropriate discharge.
Responded
Robert Howell
Concerns: Critical care information and risk needs were not effectively communicated from team leaders to direct care staff, and care plans were inaccessible, leading to a lack of understanding of resident needs and falls policies.
Responded
Kellum Thomas
Concerns: The patient lacked a cardiac monitoring device for 18 months due to a poor system for identifying battery end-of-life and excessively long replacement waiting lists. Additionally, crucial outpatient letters were significantly delayed.
Overdue
Rebecca Flint
Concerns: The Care Coordinator role is overburdened and lacks consistent job descriptions or cover during absences, compromising information flow and comprehensive patient assessment within mental health teams.
Responded
James Manning
Concerns: There's a lack of national guidance for urgent tonsillectomy referrals in children, especially regarding choking hazards. Delays in care occurred due to staff leave, poor communication between trusts, and inadequate incident investigation systems across company sites.
Overdue
Kathryn Millard
Concerns: Critical treatment plans were undocumented and unimplemented, nursing staff were unaware of key medical directives, and unidentified staff failed to record patient reviews despite deterioration concerns.
Responded
Remi Koduah
Concerns: The resuscitation area was separate from the operating theatre, hampering communication. Critical blood supplies were also located too far away for time-sensitive emergency situations.
Overdue
Surekha Shivalkar
Concerns: A lack of formal preoperative risk assessment, poor communication between surgical teams, and inadequate monitoring of a surgeon's early departure contributed to a failure to identify a critically ill patient.
Overdue
Jos Tartese-Joy
Concerns: A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.
Responded
Maziellie Mackenzie
Concerns: The mental health unit lacked a written policy for granting group leave, mandatory risk assessments, and clear staff-to-patient ratios, creating significant safety risks for patients.
Responded
Eva Wheeler
Concerns: Communication errors led to delayed ambulance calls and incorrect patient preparation. The hospital lacks robust processes for documenting/chasing emergency ambulances, clear NBM protocols, and joint registrar consultation for common conditions like bowel obstructions.
Responded
David O’Brien
Concerns: Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use of the mobility aid.
Overdue
Martin Brown
Concerns: Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.
Responded
Caden Stewart
Concerns: Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.
Responded
Alex Shaw
Concerns: Critical patient information was poorly communicated and documented between hospital clinicians during telephone consultations, leading to potentially inappropriate advice and highlighting a lack of clear standards for inter-hospital information exchange.
Responded
Macaulay Wilson
Concerns: A GP practice used imprecise language when referring a patient, failing to specify a catheter *change* as instructed by the hospital, which led to incorrect care being provided by district nurses.
Responded
William Simons
Concerns: The hospital's tele-tracking system led to communication breakdown and confusion over patient transport, with porters unaware of fall risks and unclear roles regarding patient assistance.
Responded
Elizabeth Pamment
Concerns: A care home failed to record and follow explicit instructions to contact a daughter during an emergency, leading to the resident being left unaided for hours after a fall.
Responded
Andrew Gibbins
Concerns: A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.
Responded
Katy Samuels
Concerns: The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Responded
Sarah Gibbs
Concerns: Inadequate communication between staff teams, especially during night handovers, and uncertainty regarding the consistent use of effective communication tools like SBARD were identified.
Responded
Rebecca Hursey
Concerns: Policy violations in patient observations, inadequate handover procedures, and a prolonged, unsuccessful search for appropriate alternative placement negatively impacted the patient's mental state and ability to manage self-harm risks.
Overdue
Sarah Young
Concerns: A significant delay in obtaining a neurological opinion and a failure of the medical team to review the patient in ED, exacerbated by unreliable referral systems, led to a delayed diagnosis and treatment.
Overdue
David Potts
Concerns: Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
Overdue
Mary Jones
Concerns: Inadequate out-of-hours transfer for a frail patient led to delayed risk assessment, compounded by poor fluid chart documentation, lost records from an IT merger, and a lack of nutrition referrals.
Overdue
Amy Allan
Concerns: Critical information sharing failures between hospital departments, absence of pre-operative ECMO assessment and post-operative planning, conflicting extubation advice, and delayed ECMO commencement critically compromised patient care.
Responded
Muhammed Haleem
Concerns: The NWAS system contained outdated DNA-CPR guidance for paramedics, and communication between community paediatric teams and emergency services regarding advance care plans was insufficient.
Responded
Karis Braithwaite
Concerns: Crucial risk information from first responders was not consistently documented, uploaded, or communicated to the mental health assessment team, highlighting a systemic failure in handover procedures.
Overdue
Tamsin Grundy
Concerns: A lack of continuity of care, with the patient seeing many different staff members, adversely impacted her mental health. Despite being noted, no definitive action was taken to address this issue.
Responded
Calary Davis
Concerns: Maternity services suffered from an incomplete action plan, institutional stress from a merger, a culture of not performing essential procedures at night, poor information sharing, insufficient staffing, and a lack of leadership.
Responded
Mary Johnson
Concerns: Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Responded
Gail Bailey
Concerns: A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.
Overdue
Bradley Morgan
Concerns: Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.
Responded
Derek Smith
Concerns: Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Overdue
Catherine Kennedy
Concerns: Miscommunication between ward staff and an on-call doctor led to a significant delay in patient review after an overdose, highlighting the lack of a consistent communication paradigm.
Responded
Philip Powell
Concerns: Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Responded
Doreen Wilkins
Concerns: Carer rotas lack travel time allowance, leading to late arrivals for time-critical care, shortened visits, and clients not receiving the full duration of assessed care.
Responded
Mohammad Ashraf
Concerns: Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.
Responded
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Rayan Ahmed
Concerns: Inadequate handover procedures in the special care unit mean nurses may care for unfamiliar babies during breaks, highlighting a need for comprehensive handover covering all potential responsibilities.
Overdue
David Moran
Concerns: The Trust's referral urgency guidance was imprecise, lacking a default to urgent in cases of doubt or absent screening. Communication between administrative, nursing, and clinical staff also appeared ineffective.
Responded
David Cooper
Concerns: Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Overdue
Lita Serkes
Concerns: Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.
Responded
Jane Stables
Concerns: Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.
Responded
Winifred Elliott
Concerns: The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.
Overdue
John Atkinson
Concerns: Inadequate risk assessments, poor communication between mental health professionals and family, and systemic failures in managing patients of departing staff and accessing home treatment services.
Responded
Patrick Steer
Concerns: Significant communication breakdown and lack of liaison between different specialist medical teams (surgical and coronary care) when providing shared patient care, risking adverse treatment outcomes.
Overdue
Michaela Thompson
Concerns: Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Responded
Martha Davies
Concerns: Serious communication breakdowns, over-reliance on junior/agency staff, and a lack of prompt response to patient deterioration contributed to significant care failings and poor documentation.
Overdue
Freda Weston
Concerns: Premature discharge, critical delays in antibiotic administration due to severe staff shortages, and staff unfamiliarity with escalation guidelines were identified. Handover sheets were also destroyed.
Responded
Matthew Crowley
Concerns: A&E delays due to short-staffing prevented timely triage and immediate senior doctor review. There was a delay in patient ownership, decision-making, and communication failure during transfer to ITU.
Overdue
Alan Tear
Concerns: Post-operative instructions were not followed, and rising EWS observations were not reported to medical staff. Communication between interventional radiology and nursing teams regarding observations was unclear.
Responded
Harry Pryal
Concerns: A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Responded
Michael Hanlon
Concerns: An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Responded
Brian Gillard
Concerns: A critical breakdown in patient handover between hospital departments led to ward staff being unaware of a patient's need for ambulatory oxygen, resulting in the patient being left unsupervised without oxygen and suffering a cardiac arrest.
Overdue
Tamara Holboll
Concerns: The trust lacks precise definitions for "good communication," failing to specify exactly what information, by whom, when, and how it should be exchanged, especially between clinicians and bed managers.
Responded
Archie Hexall
Concerns: A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.
Responded
Daniel Strickland
Concerns: Deficient information management included a lack of written handovers, inaccurate logs, an inaccessible daily log, and no clear method for sharing critical medical information with external parties.
Overdue
Awa Jeng
Concerns: A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Responded
Antonio Allen
Concerns: Midwives were repeatedly uncontactable for an overdue home birth, leading to the delivery being performed by family members before their eventual arrival.
Responded
Dayani Chauhan-Ahmed
Concerns: Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Responded
Ryan Boyle
Concerns: Police force control lacked adequate training for pursuit operators, an efficient notification system for pursuits, and sufficient staffing on the 'Force desk' to manage incidents effectively.
Responded
Winifred Dennis
Concerns: Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Responded
Margaret Walker
Concerns: Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Responded
Barbara White
Concerns: Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
Overdue
Sean Seabourne
Concerns: Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Overdue
Christopher James Morgan
Concerns: The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Overdue
Susan Jill Hammond
Concerns: Critical allergy information was overlooked due to inadequate flagging on patient files, and a poor handover during transfer by an uninformed nurse led to a communication breakdown.
Response: United Lincolnshire Hospitals NHS Trust has revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergies, and updated prescription charts to include prompt statements. They have also …
Pending
Joanne Manning
Concerns: A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.
Overdue
Brian Belfield
Concerns: Failures in race management included an inaccurate system for tracking participants, lack of a single responsible person for checks, and unreliable communication between race control and marshals, leading to a missing runner.
Overdue
Nicola Matthews
Concerns: Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
Overdue
Jamie Bennett
Concerns: Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.
Pending