Recurring concern

Failure to escalate patient-safety concerns to senior oversight

First to latest report 27 Nov 2013 — 6 Feb 2026

Reports that mention this concern
14
Times this concern has been raised
15
Stated actions linked to this concern
20

What this concern includes

Includes failures by clinical, care or operational staff and teams to recognise, report or escalate patient-safety concerns, significant care problems or serious safety matters promptly through the appropriate senior-staff or senior-management pathway.

What is not included
  • Excludes failures to act after a safety concern has already been escalated; those concern senior oversight response rather than upward escalation.
  • Excludes escalation processes for non-safety matters, routine administrative issues or ordinary performance concerns.
  • Excludes escalation within a separately named safety system or pathway when that system provides the more specific supported boundary.
  • Excludes failures involving escalation of a clinical deterioration episode where the concern is solely obtaining immediate clinical treatment rather than reporting the underlying safety concern to senior oversight.

Reports and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Nottinghamshire

    AI-generated summary

    Michael Richard Drewry · 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

    Michael Richard Drewry had a history of anxiety and low mood, with deteriorating mental health and episodes involving knives shortly before he was found with a ligature around his neck on 3 April 2017. He sustained fatal injuries, suffered an unsurvivable hypoxic brain injury, and died in hospital on 8 April 2017. The substantive concerns were failures by the Crisis Team to provide consistent and continuous care, make accurate and prompt records, and escalate concerns appropriately and promptly.

    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 promptly report or escalate matters of concern to senior staff

    Wider context from the report

    “(3) The failure of the Crisis Team promptly to report/escalate any matters of concern to senior members of staff so that appropriate and timely steps could be taken in relation to the management of the deceased’s care including, if necessary, hospitalisation; ”

    Source location

    Michael Richard Drewry · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind staff of escalation procedures and the importance of timely input during team meetings and monthly managerial supervision.

    Verbatim wording from the response

    “When staff are concerned following a contact with a patient, these concerns must be escalated to senior members of staff. This can be done through the daily handover of patients who are on RED in the RAG rating alongside any other patients causing concern and a doctor is present at these meetings. There is also a line management structure through which issues can be escalated to senior managers and staff have been reminded of this process which is included in the operational procedure.”

    Source location

    2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 12 February 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing handover, line-management escalation, and multidisciplinary meeting arrangements are relied upon to manage and escalate patient concerns safely.

    Verbatim wording from the response

    “Crisis Team staff are fully aware the need to escalate any concerns regarding a difference in presentation of any patient.”

    Source location

    2017-0386-Response-by-Nottinghamshire-Healthcare-NHS-Trust
    Page 2 · response
    Published 12 February 2018

    Open published response

  2. West Sussex

    AI-generated summary

    Jean Stockley · 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

    Jean Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.

    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

    Reluctance among nursing staff to escalate to senior doctors

    Wider context from the report

    “3. The nurse who had monitored Mrs Stockley throughout the night and contacted the junior doctor when the NEWS score spiked handed over to the day nurse shortly after her conversation with the doctor. From evidence heard at inquest, there may still be reluctance for nursing staff to contact doctors at a more senior level if a junior doctor does not take appropriate action such as a patient review. ”

    Source location

    Jean Stockley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.

    Verbatim wording from the response

    “2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Remind Twineham ward nursing staff to escalate patient concerns to the nurse in charge.

    Verbatim wording from the response

    “3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 August 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Roster a trained senior Band 6 nurse on Twineham ward throughout the 24-hour period to provide guidance and support escalation.

    Verbatim wording from the response

    “3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

    Source location

    2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 August 2016

    Open published response

  3. Inner West London

    AI-generated summary

    Laxmi Himatlall THAKKER · 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

    Laxmi Himatlall Thakker fell at home and was admitted to Croydon University Hospital, where her deterioration after surgery was not recognised promptly. She collapsed and was not diagnosed or treated for bleeding and vascular injury until several hours later, was transferred to St George’s Hospital in critical condition, and died in intensive care on 29 September 2014. The principal concerns included the lack of bedside observation charts, failures to escalate concerns, communication and training problems, delays in administering blood, and inadequate escalation to senior staff.

    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

    Lack of timely escalation of clinical concerns from junior to senior staff

    Wider context from the report

    “5. Lack of escalation of clinical concerns from junior to senior staff at CUH, and in particular that a patient could collapse, be seen by a junior from another treating team and the patient’s own senior team not be promptly informed, as well lack of escalation of clinical issues within the same team. ”

    Source location

    Laxmi Himatlall THAKKER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Berkshire

    AI-generated summary

    Edna Elsie Mary Eden · 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

    Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

    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 unresolved clinical review access problems to senior staff

    Wider context from the report

    “(3) Nursing staff were not able to make contact with Doctors to review Mrs Eden. When this continued, the problem was not escalated to more senior staff. ”

    Source location

    Edna Elsie Mary Eden · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 of junior staff to escalate clinical concerns to senior staff

    Wider context from the report

    “(5) Junior staff on a very busy shift appeared reluctant, or ignorant of the procedures, to escalate concerns to more senior staff to address a significant backlog that had developed. ”

    Source location

    Edna Elsie Mary Eden · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a 24-hour Central Hub with patient tracking, referral and bleep management, workload oversight, handover, task allocation, escalation and senior-manager staffing.

    Verbatim wording from the response

    “The Trust has plans to introduce a 24 hours a day Central Hub system and the timescales for actions are stated in the enclosed action plan. It is envisaged the Hub will be located at Wexham Park Hospital and be equipped with IT systems and run by senior managers who will be responsible for ensuring the following:”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026