Recurring concern
Failure to provide timely medical review of admitted patients
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Request correctionFirst reported 4 Oct 2013•Latest report 17 Jun 2025
What this concern includes
Includes failures of the inpatient medical-review process involving absent, delayed or insufficiently timely review of admitted or transferred patients, including review prompted by clinical observations, deterioration, presenting symptoms or a request from ward staff.
Not included
- Excludes delays limited to consultant review where the broader medical-review process is not deficient.
- Excludes nursing observations, monitoring or escalation failures when no failure to provide medical review is identified.
- Excludes generic staffing, documentation, communication or handover deficiencies unless they directly result in absent or delayed medical review of an admitted patient.
- Excludes outpatient, community or non-inpatient clinical reviews.
- Reports
- 24
- Individual concerns
- 27
- Date range
- 2013–2025
- Stated actions
- 35
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
Failure to provide clinical review and monitoring after ward transfer
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
Implement separate Acute Medicine Consultant cover for telephone calls while another consultant sees requested patients.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to escalate EWS scores of 3 for medical review and increased observations
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.4
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Action
Provide staff with support to understand and use the current escalation system.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Implement NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Appoint a NEWS2 Champion.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Action
Conduct ongoing audits of NEWS2 documentation and escalation.
Stated by the Queen Elizabeth Hospital, King'S Lynn, 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
Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to provide medical review on the acute medical unit
This report raised 9 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 review patients after acute NEWS score deterioration
This report raised 3 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.5
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Action
Adopt SBAR documentation and a dedicated form for recording critical telephone conversations in patient health records.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Provide a 24-hour Critical Care Outreach Team service at Princess Royal Hospital to support deteriorating patients.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.
Stated by University Hospitals Sussex NHS Foundation Trust
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Action
Remind Twineham ward nursing staff to escalate patient concerns to the nurse in charge.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Roster a trained senior Band 6 nurse on Twineham ward throughout the 24-hour period to provide guidance and support escalation.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to arrange follow-up medical review after a fluid challenge
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
Failure to provide senior review and follow up suspected infection
This report raised 18 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
Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to provide senior clinical review
This report raised 24 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
Increase permanent Acute Medical Unit staffing, including matron input, an additional senior nurse and a support assistant role.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Delays in obtaining timely medical review of concerning or pathological CTG traces
This report raised 6 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 provide medical review
This report raised 6 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.2
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Action
Improve participation by all on-call teams in refreshed hospital-at-night meetings to review patients flagged as at risk.
Stated by Barts Health NHS Trust -
Action
Send written and verbal instructions requiring junior doctors to record out-of-hours review needs on the trauma sheet before ending shifts.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to escalate changes in patient condition for timely medical assessment
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