A recent Coroner’s PFD report highlights risks for future deaths posed by agency staff

Evelyn Rae’s death at 23 hours old in April 2022 was investigated at inquest in September 2025. The medical cause of death was:
1a. Disseminated Intravascular Coagulopathy and Persistent Pulmonary Hypertension of the Newborn. 
1b. Sepsis. 

She had become unwell when less than 10 hours old with respiratory distress caused by an infection identified as being caused by Group B Streptococcus, for which her mother was found to test positive. The Coroner found that although Evie’s mother was seen twice by the midwifery team, they did not elicit concerns Evie’s parents had about Evie’s crying and breathing, nor did they afford an opportunity for these concerns to be shared. This led to neonatal assessments not being carried out nor any escalation to the hospital’s neonatal team, which contributed to the death together with a delay in administering antibiotics. Her death was contributed to by neglect. 

In the PFD (Evelyn Rae Le Masurier-O’Sullivan: Prevention of future death report - Courts and Tribunals Judiciary), the Coroner referred to the plethora of maternity initiatives over recent years and how, despite these, and the extensive steps the NHS trust in question took to strengthen its maternity and neonatal service following Evie’s death, a training gap was nonetheless identified - and that gap is likely to exist at most NHS trusts - giving rise to a risk of future deaths.

Maternity initiatives

Maternity initiatives referenced in this PFD and in the insight by Weightmans healthcare lawyers, Alison Brennan and Rebecca Taylor, The NHS Medium Term Planning Framework, include:

Aligned with the principles behind maternity-specific initiatives is Martha’s Rule. This is also referred to in the PFD that noted the NHS trust involved was amongst the first maternity and neonatal units in the country to implement Martha’s Rule within their service. The aim of Martha’s Rule is to give patients in NHS hospitals (and those acting on their behalf) the right to request a rapid review from another team at the same hospital if it is felt that they are deteriorating but action has not been taken, or it appears that concerns are not being taken sufficiently seriously by medical staff. This is not the same as a second opinion which would usually be provided by other clinicians in the same treating field and not as urgently.

The Coroner’s concerns

The Coroner received evidence that all temporary staffing supplied at the hospital involved, including midwives, is provided by “On-Framework” suppliers under framework RM6281 and most trusts – including the trust involved – do not provide in-house training to agency staff as they do not have funding to do so. Agency staff will probably not, therefore, receive training in eliciting parents’ concerns about a baby’s wellbeing at postnatal contacts. 

Agency statistics

• Temporary Staffing Spend: Expected spend by NHS providers on temporary staffing in 2024/25 was £8.3 billion, down from nearly £10 billion in 2023/24. Of this, £6 billion was on bank staff and £2.3 billion on agency staff.
• Agency Spend Reduction: Agency spending fell by almost £1 billion in 2024/25, following government targets to cut usage by 30%. Previous annual spend was around £3 billion.
• Vacancy Pressure: NHS vacancy rates remain high, with over 110,000 open posts, driving reliance on temporary staff.

Agency risks

• Knowledge Gaps: Temporary staff may lack familiarity with local protocols, IT systems, and escalation routes, increasing clinical risk.
• Compliance Burden: Trusts remain responsible for verifying identity, qualifications, and DBS checks, even when agencies supply staff.
• Litigation Exposure.

Risk reduction steps 

• Structured Onboarding
  • Orientation packs covering local policies and escalation procedures.
  • Completion of a local induction checklist before first shift.
• Close Supervision
  • Assign a named supervisor for agency staff during initial shifts.
  • Real-time support channels for urgent queries.
• Prescriptive Agency Contracts
  • Mandate agencies to evidence compliance with NHS Employment Check
  • Standards and pre-induction training.
• Strengthen Bank Workforce
  • Expand staff banks to reduce reliance on external agencies and ensure familiarity with local systems.
• Governance and Monitoring
  • Regular audits of temporary staff performance and compliance.
  • Include agency usage in risk registers and board assurance frameworks.

Policy Review

• Embed mandatory induction protocols for all temporary staff.
• Specify agency obligations for training and compliance.
• Align with NHS England’s agency reduction targets and oversight metrics.

Further reading can be found here — NHS England » Guidance for developing a healthy nursing staff bank