Recurring concern
Unreliable clinical review of observation charts
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Request correctionFirst reported 2 Feb 2016•Latest report 2 Dec 2023
What this concern includes
Includes failures of the process for reviewing and assessing completed patient observation charts, including absent or unclear review protocols, missed review of charts, and failure to detect or escalate clinically significant concerns shown by chart information.
Not included
- Excludes failures to perform or record observations where the observation-chart review process is not itself deficient.
- Excludes generic clinical-record, staffing, training or communication deficiencies unless they directly impair review of observation charts.
- Excludes failures of condition-specific systems such as NEWS operation, CTG review or neurological observations when that named system is the more specific supported concern.
- Excludes failures to act after observation-chart concerns have been reliably identified and escalated.
- Reports
- 3
- Individual concerns
- 4
- Date range
- 2016–2023
- Stated actions
- 1
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 raised2
Lack of clarity over the timing of observation chart checks
Lack of clarity over responsibility for checking observation charts
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.1
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Action
Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Stated by Devon Partnership NHS Trust
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Concerns raised1
Failure to detect concerns in completed observation charts
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 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 protocols for doctors to regularly review and assess observation charts
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026