Staff rota communication
Failures in communicating staff rota changes directly to staff members, relying solely on electronic system updates.
182 items
14 sources
3 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
John Atkinson
The coroner identified a lack of updated risk assessments, failure to identify changes in presentation and risk level, absence of a system for managing patients of departing staff, and ineffective communication among mental health professionals and with the patient and family.
Matched on
terms: communication, staff
CQC action
84match
Care Outlook (Bellerophon House)
The regional manager added this to the action plan for the service to ensure any changes to staff rotas are made through direct communication with the staff member rather than changes to the rota in the electronic system used by staff.
Matched on
terms: communication, rota, staff
PFD report
73match
Dayani Chauhan-Ahmed
Ineffective communication systems and unclear escalation policies hindered timely intervention during labor, compounded by insufficient staff availability during periods of high demand.
Matched on
terms: communication, staff
PFD report
73match
Matthew Crowley
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.
Matched on
terms: communication, staff
PFD report
73match
Derek Smith
Poor communication between the District Nursing team, family members, and other agencies, alongside issues with nursing record availability, hindered patient care and decision-making.
Matched on
terms: communication, staff
PFD report
69match
Alan Tear
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.
Matched on
terms: communication, staff
PFD report
69match
Martha Davies
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.
Matched on
terms: communication, staff
PFD report
69match
David Moran
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.
Matched on
terms: communication, staff
PFD report
69match
Catherine Kennedy
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.
Matched on
terms: communication, staff
PFD report
69match
Bradley Morgan
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.
Matched on
terms: communication, staff
PFD report
69match
Mary Johnson
Poor communication between staff regarding pre-operative patient feeding and medication adherence, combined with porter availability dictating theatre operations, raised significant safety concerns.
Matched on
terms: communication, staff
PFD report
65match
Sean Seabourne
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.
Matched on
terms: communication
PFD report
65match
Christopher James Morgan
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.
Matched on
terms: staff
PFD report
65match
Brian Belfield
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.
Matched on
terms: communication
CQC action
65match
Holly House Residential Care Home
The provider must ensure that staffing rotas accurately demonstrate staffing numbers, reflect all shifts worked, and reconcile with payroll records and actual hours worked.
Matched on
terms: rota, staff
PFD report
61match
Margaret Walker
Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical care delays.
Matched on
terms: staff
PFD report
61match
Ryan Boyle
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.
Matched on
terms: staff
PFD report
61match
Tamara Holboll
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.
Matched on
terms: communication
PFD report
61match
Harry Pryal
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.
Matched on
terms: communication
PFD report
61match
Robert Cardwell
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.
Matched on
terms: communication
PFD report
61match
Mohammad Ashraf
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.
Matched on
terms: communication
PFD report
61match
Philip Powell
Delays in ordering wound care supplies were caused by poor communication and inadequate systems regarding the ordering process and overall responsibility.
Matched on
terms: communication
PFD report
61match
Tamsin Grundy
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.
Matched on
terms: staff
PFD report
61match
Muhammed Haleem
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.
Matched on
terms: communication
CQC action
59match
Monaveen
The provider must ensure governance systems sustain improvements and address failures in communication and engagement with people and staff.
Matched on
terms: communication, staff
PFD report
57match
Nicola Matthews
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.
Matched on
terms: staff
PFD report
57match
Susan Jill Hammond
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.
Matched on
terms: communication
PFD report
57match
Joanne Manning
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.
Matched on
terms: communication
PFD report
57match
Barbara White
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.
Matched on
terms: staff
PFD report
57match
Archie Hexall
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.
Matched on
terms: communication
PFD report
57match
Brian Gillard
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.
Matched on
terms: staff
PFD report
57match
Freda Weston
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.
Matched on
terms: staff
PFD report
57match
Michaela Thompson
Multi-disciplinary team meetings were inadequately documented, and critical patient phone calls were not recorded or communicated to relevant mental health staff.
Matched on
terms: staff
PFD report
57match
Winifred Elliott
The removal of crucial resident transfer information from display in care homes hinders busy staff, potentially leading to inappropriate transfers and injuries for residents.
Matched on
terms: staff
PFD report
57match
Jane Stables
Ineffective communication between nurses and the general practitioner regarding a patient's ongoing significant pain levels impeded the provision of appropriate care.
Matched on
terms: communication
PFD report
57match
Patrick Steer
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.
Matched on
terms: communication
PFD report
57match
Doreen Wilkins
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.
Matched on
terms: rota
PFD report
57match
Gail Bailey
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.
Matched on
terms: communication
PFD report
57match
Calary Davis
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.
Matched on
terms: staff
PFD report
57match
David Potts
Critical medication (Beriplex) was not administered promptly, its delivery was unchecked, and staff lacked awareness regarding its non-administration and the patient's location.
Matched on
terms: staff
PFD report
57match
Karis Braithwaite
Important risk information provided by a paramedic was not available to the MHA assessment team, and insufficient steps have been taken to improve the handover process from first responders to Trust staff following serious incidents in the community.
Matched on
terms: staff
ICIBI recommendation
55match
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and that staff have a means of communicating upwards that is seen to be effective.
Matched on
terms: communication, staff
ICIBI recommendation
55match
An inspection of Border Force operations at Stansted Airport
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and that staff have a means of communicating upwards that is seen to be effective.
Matched on
terms: communication, staff
IMB recommendation
55match
Sudbury (2024)
The Board has continued to note that some prisoners perceive there to be inconsistencies between the OMU staff, in terms of processing ROTL applications, but also acknowledges the recent changes to the systems in use and the appointment of additional management in the area. An ongoing concern raised by prisoners is the lack of regular communication between them...
Matched on
terms: communication, staff
PFD report
53match
Michael Hanlon
An inefficient boat entry system, potential crew tiredness from additional shifts, and inadequate monitoring of working hours raised safety concerns for crewmembers.
Matched on
classifier match
PFD report
53match
Sarah Young
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.
Matched on
classifier match
CQC action
52match
Affinity Trust Specialist Support Division North
People's needs and any changes in their care and support was not always shared with staff.
Matched on
terms: staff
IOPC learning recommendation
52match
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police clarify and/or implement/formalise an escalation process when there are outstanding matters to be resourced. Due to the lack of policy, some staff members inform their supervisors whilst other do not. This incident was left outstanding for 26 hours. The IOPC is aware that Derbyshire have implemented some fast track learning around this...
Matched on
terms: staff
IMB recommendation
51match
Ford (2021)
Communication has continued to be a problem. During lockdown you held regular forums attended by a representative from each corridor but the information given out did not seem to reach the other prisoners in spite of the fact that the forums were each followed up by a notice to the community. Prisoners also reported that communication with staff,...
Matched on
terms: communication, staff
IMB recommendation
51match
Five Wells (2023)
The Board’s rota reports have highlighted that inconsistencies and frequent changes in regime have undermined the running of the houseblocks, with some staff feeling unsupported and lacking the confidence to enforce where necessary. What action will be taken to remedy this?
Matched on
terms: rota, staff