First reported 29 Sep 2015•Latest report 13 Mar 2025
Definition
What this concern includes
Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable paediatric early warning score (PEWS) systems’ and satisfy this evidence boundary: Three distinct reports directly support outdated or inconsistent PEWS scoring and absent prompt-review arrangements after PEWS alerts. Excludes all general adult EWS and NEWS assertions; they belong to the consolidated Early Warning Score parent recorded at position 149. The later membership-overlap stage must partition PEWS-specific assertions from that broader parent.
Not included
Excludes generic clinical deterioration, staffing, training or communication deficiencies that are not specifically tied to PEWS scoring or escalation.
Excludes failures in carrying out clinical review after a PEWS alert when the PEWS scoring and alert-to-review process itself operated reliably.
Excludes other early-warning, triage or observation systems unless the assertion explicitly concerns PEWS or its directly associated escalation process.
Excludes failures limited to documentation of observations or scores where PEWS scoring and escalation operated correctly.
Excludes manifestations outside the manually reviewed boundary: Three distinct reports directly support outdated or inconsistent PEWS scoring and absent prompt-review arrangements after PEWS alerts. Excludes all general adult EWS and NEWS assertions; they belong to the consolidated Early Warning Score parent recorded at position 149. The later membership-overlap stage must partition PEWS-specific assertions from that broader parent.
Reports
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
9
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care3
NHS England2
Barts Health NHS Trust1
Care Quality Commission1
Royal College of Emergency Medicine1
Royal College of Paediatrics and Child Health1
Royal Free Hospital1
The Children's Trust1
Ministerial department3
Executive non-departmental public body2
Health and social care service regulator1
Healthcare site1
Health professional body1
NHS trust1
Professional body1
Registered charity1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner North London
Concerns raised1
Failure to include blood pressure in the national paediatric early warning score
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Implement the national PEWS approach in the electronic patient record by the national deadline.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Action
Use a cross-site multidisciplinary working group to oversee PEWS implementation, education, staffing, guidelines and risk evaluation.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Include blood pressure as an observation in the national paediatric early warning score.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Collaborate with NHS England and the Royal College of Nursing to develop a single national PEWS for England.
Stated by Royal College of Paediatrics and Child HealthStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Although blood pressure was not recorded, it was likely normal and would not have changed Billie’s outcome.
Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
National PEWS is not currently supported for use in emergency departments; an ED-specific version is being developed and tested.
Stated by Royal College of Emergency MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Failure to undertake regular Paediatric Early Warning Score assessments
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Lack of a system ensuring prompt clinical review after PEWS alerts
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Share learning about early senior review of deteriorating patients and PEWS escalation protocols widely among clinical staff.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No additional intervention would have prevented the outcome, given the senior specialist review within 20 minutes of the PEWS increase.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to standardise PEWS scoring systems and escalation processes across trusts
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North London
Concerns raised2
PEWS scores distracting doctors from serious illness despite low scores
PEWS scores not reflecting current research into child illness
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A single nationally recommended PEWS score cannot yet be established because children’s differing needs make development complex and research is ongoing.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable paediatric early warning score (PEWS) systems’ and satisfy this evidence boundary: Three distinct reports directly support outdated or inconsistent PEWS scoring and absent prompt-review arrangements after PEWS alerts. Excludes all general adult EWS and NEWS assertions; they belong to the consolidated Early Warning Score parent recorded at position 149. The later membership-overlap stage must partition PEWS-specific assertions from that broader parent.
