Recurring concern
Unreliable activation of emergency medical response teams
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Request correctionFirst reported 16 Apr 2014•Latest report 23 Oct 2025
What this concern includes
Includes failures of dedicated emergency medical team activation processes, including unclear activation criteria, missed or delayed calls, and failures to link deterioration or escalation triggers to activation of the appropriate emergency medical response team.
Not included
- Excludes general failures to recognise or respond to clinical deterioration when no emergency medical response-team activation issue is identified.
- Excludes delays in treatment or attendance after an emergency medical response team has been activated.
- Excludes generic staffing, training, communication or escalation deficiencies unless they directly impair activation of an emergency medical response team.
- Excludes non-medical emergency services and emergency alarm systems unless the assertion specifically concerns activation of an emergency medical response team.
- Reports
- 9
- Individual concerns
- 9
- Date range
- 2014–2025
- Stated actions
- 13
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of nursing staff understanding of when to call the EMRT during emergencies involving a DNAR
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to trigger a Medical Emergency call when elevated NEWS scores require medical review
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Share learning from the case and reinforce NEWS2 escalation, trigger-response-team and local escalation requirements with surgical staff.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Reiterate NEWS and local clinical escalation processes to new surgical residents during standard induction.
Stated by Mid and South Essex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Failure to activate the emergency alarm system to summon the rapid response team promptly
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of clarity about when to call the Emergency Treatment Team
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Display the Medical Emergency Team call process on NEWS charts for clinicians assessing observations.
Stated by Betsi Cadwaladr University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The NEWS chart clearly identifies when clinicians should call the Medical Emergency Team.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Delays in calling the rapid response team when non-respiration is suspected
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Deliver direct NEWS2 training to nursing staff, including escalation based on clinical judgement as well as numerical scoring.
Stated by The Trust -
Action
Provide tools and mechanisms for identifying deteriorating patients and clarify escalation routes using clinical experience alongside numerical scoring.
Stated by The Trust -
Action
Use trust-wide clinical updates, shared-learning sessions and safety bulletins to reinforce deterioration recognition and escalation.
Stated by The Trust
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Concerns raised1
Failure of resuscitation call-out criteria to identify critically ill unresponsive patients with initially normal vital signs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to report raised NEWS scores to doctors or critical care outreach
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Disseminate National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Pilot a revised observation and escalation process, with registered nurses observing patients requiring observations more frequently than every four hours.
Stated by The Trust -
Action
Emphasise Medical Emergency Team availability during mandatory basic life support training for all staff groups.
Stated by The Trust -
Action
Evaluate current nurse and doctor training on identifying deteriorating patients and develop an improvement proposal informed by cardiac-arrest learning.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing cardiac-arrest protocols, medical-emergency procedures and mandatory training are considered sufficient arrangements for activating the appropriate response.
Stated by The Trust
Data last updated 7 September 2026