Staff suitability and fitness
108 items
2 sources
Failure to ensure that employed staff possess good character, necessary qualifications, skills, experience, and physical and mental fitness for their roles.
Cross-Source Insight
Staff suitability and fitness has been flagged across 2 independent accountability sources:
69 inquiry recs
39 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (69)
R19 — Registration scheme for working with children
Recommendation: New arrangements should be introduced requiring those who wish to work with children, or vulnerable adults, to be registered. This register – perhaps supported by a card or licence – would confirm that there is no known reason why an …
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
BRIS-47 — Enable trusts to independently address healthcare professional code breaches
Recommendation: Trusts should be able to deal as employers with breaches of the relevant professional code by a healthcare professional, independently of any action which the relevant professional body may take.
Unknown
BRIS-58 — Formally assess non-clinical patient care competence for initial professional qualification
Recommendation: Competence in non-clinical aspects of caring for patients should be formally assessed as part of the process of obtaining an initial professional qualification, whether as a doctor, a nurse or some other healthcare professional.
Unknown
BRIS-63 — Provide healthcare management education for all aspiring clinical professionals
Recommendation: All those preparing for a career in clinical care should receive some education in the management of healthcare, the health service and the skills required for management.
Unknown
BRIS-65 — NHS Leadership Centre to issue guidelines on acceptable leadership styles and practices
Recommendation: An early priority for the new NHS Leadership Centre should be to offer guidelines as to leadership styles and practices which are acceptable and to be encouraged within the NHS, and those which are not.
Unknown
BRIS-66 — Identify and train potential NHS leaders, investing in leadership skills development
Recommendation: Steps should be taken to identify and train those within the NHS who have the potential to exercise leadership. There needs be a sustained investment in developing leadership skills at all levels in the NHS.
Unknown
BRIS-68 — Involve NHS Leadership Centre in all healthcare professional education and development stages
Recommendation: The NHS Leadership Centre should be involved in all stages of the education, training and continuing development of all healthcare professionals.
Unknown
BRIS-69 — Broaden healthcare professional regulation to include education, training, CPD, and revalidation
Recommendation: Regulation of healthcare professionals is not just about disciplinary matters. It should be understood as encapsulating all of the systems which combine to assure the competence of healthcare professionals: education, registration, training, CPD and revalidation as well as disciplinary matters.
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-78 — Widen medical school access for diverse academic and socio-economic backgrounds
Recommendation: Access to medical schools should be widened to include people from diverse academic and socio-economic backgrounds. Those with qualifications in other areas of healthcare and those with an educational background in subjects other than science, who have the ability and …
Unknown
BRIS-79 — GMC's 'Good Medical Practice' to inform medical school selection and curricula
Recommendation: The attributes of a good doctor, as set down in the GMC’s ‘Good Medical Practice’, must inform every aspect of the selection criteria and curricula of medical schools.
Unknown
BRIS-80 — Involve NHS and public in establishing selection criteria for healthcare professionals
Recommendation: The NHS and the public should be involved in (a) establishing the criteria for selection and (b) the selection of those to be educated as doctors, nurses and as other healthcare professionals.
Unknown
BRIS-82 — Make Continuing Professional Development (CPD) compulsory for all healthcare professionals
Recommendation: CPD, being fundamental to the quality of care provided to patients, should be compulsory for all healthcare professionals.
Unknown
BRIS-83 — Provide incentives, funding, and time for healthcare professional continuous professional development
Recommendation: Trusts and primary care trusts should provide incentives to encourage healthcare professionals to maintain and develop their skills. The contract (or, in the case of GPs, other relevant mechanism) between the trust and the healthcare professional should provide for the …
Unknown
BRIS-84 — Trusts must ensure CPD resources meet patient needs and professional aspirations
Recommendation: Trusts and primary care trusts must take overall responsibility through an agreed plan for their employees’ use of the time allocated to CPD. They must seek to ensure that the resources deployed for CPD contribute towards meeting the needs of …
Unknown
BRIS-85 — Mandate periodic appraisal for all healthcare professionals in employment contracts
Recommendation: Periodic appraisal should be compulsory for all healthcare professionals. The requirement to participate in appraisal should be included in the contract of employment.
Unknown
BRIS-86 — Expedite implementation of regular appraisal for all hospital consultants
Recommendation: The commitment in ‘The NHS Plan’ to introduce regular appraisal for hospital consultants must be implemented as soon as possible.
Unknown
BRIS-87 — Incorporate periodic appraisal requirement into General Practitioners' terms of service
Recommendation: The requirement to undergo periodic appraisal should also be incorporated into GPs’ terms of service.
Unknown
BRIS-88 — Mandate periodic revalidation for all healthcare professionals in employment contracts
Recommendation: Periodic revalidation, whereby healthcare professionals demonstrate that they remain fit to practise in their chosen profession, should be compulsory for all healthcare professionals. The requirement to participate in periodic revalidation should be included in the contract of employment.
Unknown
BRIS-89 — Involve public, employers, and professional groups in revalidation processes
Recommendation: The public, as well as the employer and the relevant professional group, must be involved in the processes of revalidation.
Unknown
BRIS-92 — Provide protected time for clinicians undertaking managerial roles beyond clinical practice
Recommendation: Where clinicians hold managerial roles which extend beyond their immediate clinical practice, sufficient protected time in the form of allocated sessions must be made available for them to carry out that managerial role.
Unknown
BRIS-94 — Appoint clinicians to managerial roles based solely on demonstrated competence
Recommendation: Clinicians should not be required or expected to hold managerial roles on bases other than competence for the job. For example, seniority or being next in turn are not appropriate criteria for the appointment of clinicians to managerial roles.
Unknown
DUNB-27 — Establish national accreditation for children's clubs with leader suitability checks
Recommendation: There should be a system for the accreditation to a national body of clubs and groups voluntarily attended by children and young persons under 16 years of age for their recreation, education or development, the main purpose of which would …
Unknown
FENN-102 — Review London Underground staff promotion policy to promote on merit
Recommendation: London Underground shall review its policy on the promotion of staff and promote more on merit.
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
27 — Professional registration for custodial care staff
Recommendation: As the Inquiry set out in its Interim Report, professional registration of the workforce in settings responsible for the care of vulnerable children complements regulation of institutions by a separate, independent regulator. The government has agreed in principle that professional …
Gov response: On 5 November 2021, the Ministry of Justice stated that it had reviewed the evidence it collected through a targeted consultation on professional registration. On 4 May 2022, the Ministry of Justice stated that it …
Accepted in Part
In progress
FR-7 — Registration of Care Home Staff
Recommendation: The Inquiry recommends (as originally stated in its Interim Report, dated April 2018) that the UK government introduces arrangements for the registration of staff working in care roles in children's homes, including secure children's homes. Registration should be with an …
Gov response: We accept that rigorous registration of staff working in care roles in children’s homes is essential and we are looking at how best to implement this as part of the Stable Homes, Built on Love …
Accepted in Part
In progress
FR-8 — Registration in Young Offender Institutions
Recommendation: The Inquiry recommends (as originally stated in its Sexual Abuse of Children in Custodial Institutions: 2009-2017 Investigation Report, dated February 2019) that the UK government introduces arrangements for the professional registration of staff in roles responsible for the care of …
Gov response: We accept the need for registration, noting that internal registration is most appropriate for the young offender institution and secure training centre workforce. We are exploring proposals for how it could operate.
Accepted in Part
In progress
12a — Suspension during investigation
Recommendation: We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional.
Gov response: Not accepted. Government does not support blanket automatic suspension. Suspension should be decided case-by-case based on risk assessment. Automatic suspension could deter reporting and be disproportionate. Existing guidance from NHS Employers and professional regulators provides …
Not Accepted
P1-1 — Non-mortuary staff accompanied in mortuary
Recommendation: Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff member when they visit the mortuary. For example, maintenance staff …
Gov response: Implemented. The Trust has implemented this requirement. All non-mortuary staff and contractors must be accompanied when visiting the mortuary. This was confirmed in NHS England's oversight meetings with the Trust. (Source: Trust assurance statement, February …
Accepted
Delivered
P1-3 — Criminal record checks compliance
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that it is compliant with its own current policy on criminal record checks and re-checks for staff. The Trust should ensure that staff who are employed by its facilities management provider …
Gov response: Implemented. The Trust mandates contractors to renew security clearances every 3 years. Policy on criminal record checks is being followed for both direct staff and contractors. (Source: Trust assurance statement, February 2024; confirmed in Written …
Accepted
Delivered
P1-4 — Mortuary Managers qualified and supported
Recommendation: Maidstone and Tunbridge Wells NHS Trust must assure itself that its Mortuary Managers are suitably qualified and have relevant anatomical pathology technologist experience. The Mortuary Manager should have a clear line of accountability within the Trust's management structure and must …
Gov response: Implemented. The Trust has reviewed Mortuary Manager arrangements and ensured appropriate qualifications and support are in place with clear lines of accountability. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 …
Accepted
Delivered
P1-5 — Mortuary Manager as full-time dedicated role
Recommendation: The role of Mortuary Manager at Maidstone and Tunbridge Wells NHS Trust should be protected as a full-time dedicated role, in recognition of the fact that this is a complex regulated service, based across two sites, that requires the appropriate …
Gov response: Implemented. The Mortuary Manager role is now protected as a dedicated full-time position. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-6 — Review policies on mortuary access
Recommendation: Maidstone and Tunbridge Wells NHS Trust must review its policies to ensure that only those with appropriate and legitimate access can enter the mortuary.
Gov response: Implemented. Policies have been reviewed and updated. Access is now controlled via individual swipe cards with appropriate restrictions. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-7 — Audit and monitor mortuary access
Recommendation: Maidstone and Tunbridge Wells NHS Trust must audit implementation of any resulting new policy and must regularly monitor access to restricted areas, including the mortuary, by all staff and contractors.
Gov response: Implemented. Regular audits of mortuary access are now conducted. Access data is monitored and reviewed. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P2-10 — Designated Individuals adequate time and resource
Recommendation: NHS trusts should ensure that Designated Individuals have enough time and resource to fulfil their responsibilities, including time for learning and development.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-13 — Mortuary Manager professional background prerequisite
Recommendation: A professional background in the field of mortuary services should be made a prerequisite for the post of Mortuary Manager.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-14 — Mortuary Manager adequate resources and support
Recommendation: NHS trusts should assure themselves that the Mortuary Manager has adequate resources and support to perform their role effectively, including meeting any reporting requirements.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-74 — HTA require suitable qualified staff with enforcement
Recommendation: The Human Tissue Authority, and/or the new inspectorate, should require the organisations it licenses to ensure that any individual who provides care to deceased people is suitably qualified, experienced and supervised. The regulatory regime should set minimum standards on the …
Gov response: This recommendation is under consideration.
Response Unclear
P2-9 — Monitor and review staff access numbers
Recommendation: All NHS trusts should monitor the number of staff with access to the mortuary or body store and keep this under routine review.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
IHRD-12 — Senior Paediatric Responsibility
Recommendation: Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.
Gov response: Arrangements in place for senior paediatric oversight in children's wards.
Accepted
Delivered
IHRD-13 — Foundation Doctors in Children's Wards
Recommendation: Foundation doctors should not be employed in children's wards.
Gov response: Reviewed in context of workforce planning. Some concerns raised by Royal Colleges about potential de-skilling impacts. Implementation being balanced against training needs.
Accepted in Part
No update 2+ yrs
IHRD-14 — Clinician Competence Assessment
Recommendation: The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.
Gov response: Competence assessment processes incorporated into recruitment procedures for paediatric roles.
Accepted
Delivered
IHRD-15 — Consultant Notification on Admission
Recommendation: A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior clinical involvement and leadership.
Gov response: Protocols implemented for consultant notification on unscheduled paediatric admissions.
Accepted
Delivered
IHRD-19 — Senior Lead Nurse in Children's Wards
Recommendation: To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff …
Gov response: Senior lead nurse roles established in children's wards across Trusts.
Accepted
Delivered
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: Trust disciplinary procedures updated to address professional code breaches independently.
Accepted
Delivered
IHRD-9 — Leadership Development
Recommendation: The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.
Gov response: Review processes strengthened. Independent oversight mechanisms enhanced.
Accepted
No update 2+ yrs
JB-15.20 — Process for firearms officer return to duty after fatal shooting
Recommendation: There needs to be proper and objective consideration by the NPCC as to whether, and if so when, it is appropriate for a firearms officer to return to active deployment following their part in a fatal shooting. Such consideration must …
Gov response: MPS formally responded on 28 October 2022 (para 38). MPS considers this a national recommendation and did not consider it appropriate to respond at this stage.
Accepted
In progress
LADB-14 — Review driver competence system effectiveness and retest drivers every three years
Recommendation: TOCs should review the effectiveness of the systems in place to deliver the required level of driver competence at least once every three years, and should retest the driver against the revised systems at the same frequency (para 9.49).
Unknown
LADB-15 — Expeditiously progress ATOC study on central licensing of drivers
Recommendation: The ATOC study on the central licensing of drivers should be progressed expeditiously (para 9.50).
Unknown
LADB-16 — Consider applying NVQs to the driver licensing scheme by ATOC
Recommendation: ATOC should consider the application of NVQs to the driver licensing scheme presently under their consideration (para 9.52).
Unknown
LADB-18 — Establish specific, validated criteria and pass standards for driver training
Recommendation: Thames Trains and other TOCs should ensure that their driver training and testing programmes adequately reflect the need for specific, relevant and validated criteria. Drivers should be tested against these criteria, and a definite pass standard should be established. Consideration …
Unknown
F172 — Proficiency in the English language
Recommendation: The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F185 — Focus on culture of caring
Recommendation: There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection of …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F188 — Aptitude test for compassion and caring
Recommendation: The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates' attitudes towards caring, compassion and other necessary professional …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F191 — Recruitment for values and commitment
Recommendation: Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F217 — Common selection criteria
Recommendation: A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F23 — Responsibility for regulating and monitoring compliance
Recommendation: The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
WATE-(24) — Mandate stringent, independent vetting for all foster parent applications, especially staff
Recommendation: Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who …
Unknown
WATE-(27) — Require senior children's home staff to be qualified social workers or train
Recommendation: It should be a requirement that senior staff of children's homes (including private and voluntary homes) must be qualified social workers or, if that is not practicable before appointment, that it should be a condition of their appointment that they …
Unknown
WATE-(48) — Ensure inspectors of children's services have substantial child care experience
Recommendation: When inspections are made by the agency of homes, schools or services mentioned in recommendation (47) at least one of the inspectors should have substantial experience of child care.
Unknown
WATE-(54) — Mandate child care expert on local authority social services management team
Recommendation: There should be at least one full member of a local authority's social services department management team with child care expertise and experience.
Unknown
WATE-(55) — Assign children's services policy and oversight to Assistant Director level manager
Recommendation: The responsibility for policy and service development and for oversight of the delivery of a local authority's children's services should be assigned to one member of the social services department management team of at least Assistant Director status.
Unknown
WATE-(56) — Ensure sufficient intermediate management staff for children's services supervision and support
Recommendation: Staffing resources at intermediate management level for a local authority's children's services should be sufficient in number and quality to enable positive and close supervision and support to be given to residential establishments and the fostering service.
Unknown
RHI-8 — Job-Specific Recruitment
Recommendation: A fundamental shift is needed in the approach used within the Northern Ireland Civil Service with regard to recruitment and selection for government jobs. This must involve an up-front assessment of the skills that are required to fulfil the specific …
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
AG-9 — Maximum Continuous Duty Period for AFOs
Recommendation: The National Police Chiefs' Council (NPCC) and the College of Policing should jointly decide, in the light of independent expert advice, whether there should be a maximum period of time during which authorised firearms officers (AFOs) are permitted to remain …
Gov response: 37. Following discussions with NPCC and the College of Policing, the Government understands that current guidance does not specify a time limit and that there would be significant operational implications of doing so. There are, …
Accepted
No update 2+ yrs
COVID-M2.1 — NI CMO Independence
Recommendation: The Department of Health (Northern Ireland) should reconstitute the role of the Chief Medical Officer for Northern Ireland as an independent advisory role. The Chief Medical Officer for Northern Ireland should not have managerial responsibilities within the Department of Health …
Gov response: No formal response published by this government.
Unknown
PFD Reports (39)
Valerie Gibson
Concerns: Staff confusion regarding medication dispensing and administration, inadequate checking of patient possessions, and inconsistent electronic record-keeping posed risks of over/under medication and patient harm.
Response: The Trust has completed comprehensive training for all nursing staff and amended its Medicine’s Management Policy to ensure medication is dispensed before administration. They have also updated e-learning packages and …
Responded
Jack Brown
Concerns: Unregulated care agencies provide staff to care homes without oversight of recruitment or training, risking vulnerable residents being cared for by unsuitable individuals lacking basic checks.
Response: The Department clarifies that the CQC regulates care providers, not staffing agencies, but providers remain legally responsible for staff suitability. The Department has revised the Care Workforce Pathway, launched the …
Responded
[REDACTED]
Concerns: There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.
Response: The East London NHS Foundation Trust states that no further action is required for most concerns due to significant work already undertaken since the patient's death, which has resulted in …
Responded
Lee Stammers
Concerns: Poor documentation, communication, and system failures led to urgent medical tests being missed or inaccurately recorded. Unidentified temporary staff could also cancel tests without accountability, risking patient harm.
Responded
Alice Clark
Concerns: Unsafe paramedic driving standards were not appropriately addressed due to the lack of a formal complaint procedure and inadequate independent assessment of driver competence.
Responded
Michael Dalkin
Concerns: The use of unlicensed door supervisors and misrepresentation of SIA-registered staff roles led to inaccurate safety registers, indicating a systemic failure in security and licensing compliance.
Responded
Barbara Rymell
Concerns: Care staff with insufficient English proficiency pose a risk to vulnerable patients by hindering effective communication with emergency services, potentially delaying urgent medical attention.
Overdue
Tarik Drakes
Concerns: Dorset Lodge, a supported housing facility, suffers from inadequate staffing, unmonitored guest entry, and poor welfare checks, creating an environment where drug use and safeguarding risks are prevalent.
Responded
Sean Duignan
Concerns: Severe security failures at the police armoury included a chronically failing access system, a widely known override PIN, and incorrect single access permissions, allowing unauthorized access to weapons.
Responded
Ruwaida Adan
Concerns: The karting venue's safety checks for loose hair and clothing are inadequate, as track marshals frequently miss hazards. Despite known issues, there's no evidence of improved training or monitoring for marshals, indicating a concerning lack of commitment to safety.
Responded
Ian Taylor
Concerns: Concerns were raised about the police officer's fitness to serve, specifically regarding their assessment and handling of a vulnerable individual who expressed suicidal ideation and required physical assistance.
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Overdue
Macloud Nyeruke
Concerns: Hospital failed to assess an agency support worker's immune status, assigning them to infectious wards without adequate PPE training, increasing infection risk to staff and patients. Nursing agencies failed to share health vulnerabilities.
Responded
Arthur Hughes
Concerns: A lack of protocol for assessing locum staff's practical skills and managerial reluctance to thoroughly check references created risks that locums might perform tasks beyond their capabilities.
Responded
Ifeoma Onwuka
Concerns: An on-call consultant lacked confidence for emergency surgery, showed poor leadership, and failed to investigate the cause of a patient's DIC, potentially putting pregnant women at risk.
Overdue
Russell Bowry
Concerns: Employers in the rigging industry delegate critical work-at-height safety to individual riggers without ensuring proper planning, supervision, or adequate safety features. This leads to routine unsafe practices, with riggers having minimal influence over their own fall protection.
Overdue
Alex Blake
Concerns: Multiple nursing staff provided unreliable and potentially false evidence regarding patient observations, with documented discrepancies between reported checks and the patient's actual status, raising serious concerns about care quality.
Responded
Polly Drew
Concerns: The recruitment process for a doctor with access to anaesthetic drugs and significant responsibility was completely inadequate, leading to her working alone and posing risks to patients.
Overdue
Kevin Miles
Concerns: The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.
Responded
Peter O’Donnell
Concerns: Private hospital care had no clear consultant review agreements, inadequate junior doctor oversight/training, absent patient transfer protocols, and failed to report nurse misconduct, creating systemic safety risks.
Responded
Cyril Anderton
Concerns: Medical staff failed to attempt CPR due to a critical error, consulting and acting upon the wrong set of patient medical notes.
Overdue
Jakub Moczyk
Concerns: Inadequate pre-fight medical checks for boxers and medics failing to assess a boxer's fitness to continue after vomiting, relying instead on a non-medically qualified referee/trainer.
Responded
John Rogers
Concerns: The health board's current systems are inadequate to ensure staff possess appropriate and up-to-date qualifications and training for their required work.
Responded
Steven Rogers
Concerns: A doctor discharged a patient without seeing them, indicating a fundamental lack of understanding of discharge importance, and staff erroneously omitted long-acting insulin during the patient's hospital stay.
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
Bradley Hooper
Concerns: An inexperienced marshall, distracted by a mobile phone and improperly positioned, failed to observe a fatal collision. Club rules for marshall allocation were not followed, and the MCF Code of Practice lacks smartphone use guidance.
Overdue
Mary Hyden
Concerns: A consultant neurologist is working excessive hours, including 7-day weeks and 14-hour shifts, which significantly increases the potential for medical errors and risks to patient safety.
Responded
Laurence Boyens
Concerns: Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff training and awareness regarding signs of patient deterioration for patients on Methadone/Buprenorphine.
Overdue
Thor Dalhaug
Concerns: Failures included unsupervised surgeons, inappropriate techniques, incomplete medical records, and a lack of candour in disclosing circumstances surrounding a neonatal death, hindering investigation and causing distress.
Responded
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Responded
Pauline Edwards
Concerns: UK hospitals allowed EU-trained doctors to practice unsupervised without ensuring equivalent training or experience, driven by EU law, thereby increasing patient risk.
Responded
Thomas Warren
Concerns: The employing Trust failed to adequately vet a locum doctor, missing critical information about previous concerns and investigations from other healthcare bodies, and relying solely on basic GMC restriction checks.
Overdue
Lloyd Butler
Concerns: A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.
Responded
Lalitaben Patel
Concerns: A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
Responded
Neil Carter
Concerns: There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Responded
Karl Doran
Concerns: The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of direct or indirect managerial supervision over their activities.
Pending
Jack William Payton
Concerns: Control room staff's judgement and handling of the matter were negatively affected by excessive working hours and heavy caseloads, raising concerns about operational capacity.
Response: The Constabulary is commissioning an independent assessment of current shift patterns and their effects on staff, anticipated to be completed by January 2014. Recommendations will be developed and considered for …
Responded
Syeda Fatima
Concerns: Significant and systemic cultural tensions, including hierarchy and bullying, between midwifery and obstetric staff contributed to critical delays in patient care and decision-making.
Responded
Kate Hyatt
Concerns: A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis sufferers.
Responded