Recurring concern

Failure to reliably escalate requests for medical review

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First reported 7 Apr 2014•Latest report 28 Mar 2025

Definition

What this concern includes

Includes failures to recognise, initiate, communicate, verbally escalate, track or follow up requests for medical review when a patient's condition or safety concern requires timely clinical assessment, including requests raised by families, carers or care staff.

Not included

  • Excludes delays caused solely by clinician unavailability after a request has been reliably escalated and accepted.
  • Excludes failures to conduct the clinical review itself when the request and escalation process operated reliably.
  • Excludes generic communication, documentation or staffing deficiencies that are not directly tied to escalating a request for medical review.
  • Excludes routine scheduled reviews where no patient-specific concern or request for timely medical assessment is identified.
Reports
14

Distinct published reports

Individual concerns
14

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
19

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.

Office of the Chief Coroner2
Recipient name withheld2
Adbolton Hall1
Cwm Taf Morgannwg University Local Health Board1
Daryel Care1
Department of Health and Social Care1
East Kent Hospitals University NHS Foundation Trust1
East London NHS Foundation Trust1
HCRG Care Coventry LLP1
Huddersfield Royal Infirmary1
Hunters Lodge1
Lancashire Teaching Hospitals NHS Foundation Trust1
London Borough of Islington1
National Institute for Health and Care Excellence1
NHS Coventry and Warwickshire Integrated Care Board1

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.

  1. Shropshire, Telford and Wrekin

    AI-generated summary

    Ivy Rebecca Morris · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ivy Rebecca Morris was born with severe perinatal hypoxic ischaemic brain damage and died at home on 3 May 2016 after becoming unresponsive during a feed. The report identified concerns about foetal heart monitoring, failures to follow midwifery guidelines, and potential delays relating to episiotomy support. The inquest concluded that appropriate monitoring during the second stage of labour would have prevented her death, according to the supplied text.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to request obstetric review for maternal tachycardia

    Wider context from the report

    “(2) Failure to follow midwifery guidelines. a. To confirm assessment of the CTG using the agreed assessment tool. b. The need to request an obstetric review after 1 hour of active pushing. c. The need to request an obstetric review for maternal tachycardia. ”

    Source location

    Ivy Rebecca Morris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. West Yorkshire (Western)

    AI-generated summary

    Phillip Roy Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to obtain appropriate senior medical review or support when deterioration is identified

    Wider context from the report

    “(3) Junior Doctor’s Involvement i) The senior nurse on duty was concerned of Mr. Smith’s deterioration in the early hours of the 15th March. At the time of the junior doctor’s attendance she suggested that a more senior medical review should take place, however the junior doctor indicated that he did not require any further support in the circumstances notwithstanding Mr. Smith’s presentation. ”

    Source location

    Phillip Roy Smith · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Brighton and Hove

    AI-generated summary

    LINDA ANNE RIGNALL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Linda Anne Rignall's condition changed on 5 May 2014, but the change was not reported to a doctor and she was not assessed; her condition worsened approximately four hours later without a medical review. The report states that this failure to refer her for assessment resulted in the only available window of opportunity to treat her being lost, raising concern about the Acute Medical Unit's fitness for purpose.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate changes in patient condition for timely medical assessment

    Wider context from the report

    “(1) At 17:33 on the 5th May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart. This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have been assessed. The position worsened some 4 hours later (the next time observations were performed) and there was still no request for a medical review. From the evidence it was clear to me and I found as you will see from the Conclusion that I recorded that this failure to refer Miss Rignall for assessment resulted in the only window of opportunity available to treat her, being lost. This makes me concerned as to AMU's Fitness for Purpose at the current time. I consider this to be serious. ”

    Source location

    LINDA ANNE RIGNALL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Central and South East Kent

    AI-generated summary

    William Albert Winter · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Albert Winter was admitted to hospital after discharge from St Thomas’ Hospital following surgery for repair of an abdominal aortic aneurysm, and was found unresponsive with rigor mortis at approximately 5am on 26th March 2013. Nursing staff were concerned that he had not been reviewed by the surgical team, and a second set of observations was not carried out or escalated as required amid pressures on the Clinical Decisions Unit.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate outstanding requests for surgical review

    Wider context from the report

    “Mr Winter was admitted to the CDU at 8pm and the nursing staff were concerned that he had not been reviewed by the surgical team. They missed carrying out a second set of observations soon after 2am on 26th March 2013 owing to the pressures on them to care for other patients on the Clinical Decisions Unit. Mr Winter was found in an unresponsive state at approximately 5am on 26th March 2013 when efforts were made to resuscitate him during which it was noted that rigor mortis had already developed. I heard evidence that there were 19 admissions and discharges to and from the CDU overnight with 4 members of nursing staff. It was apparent that whilst keeping an eye on Mr Winter, they did not carry out a second set of observations when they should have done nor did they escalate their request for a surgical review. They were unfamiliar with how to do this. ”

    Source location

    William Albert Winter · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026