Recurring concern
Unreliable escalation of abnormal clinical observations
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Request correctionFirst reported 24 Sep 2013•Latest report 17 Nov 2025
What this concern includes
Includes failures in the dedicated process for recognising, interpreting, thresholding, communicating, reviewing or escalating abnormal clinical observations, including physiological, neurological and early-warning observations, where the deficiency can delay appropriate care.
Not included
- Excludes general clinical deterioration failures where no abnormal-observation trigger or observation-based escalation process is identified.
- Excludes failures to perform or record observations when no associated failure to recognise, review or escalate abnormal findings is asserted.
- Excludes failures limited to communicating an already recognised observation to a specific recipient when the broader observation-escalation process is not deficient.
- Excludes condition-specific assessment or treatment pathways where abnormal observations are only incidental and the named condition supplies the more specific supported boundary.
- Reports
- 39
- Individual concerns
- 44
- Date range
- 2013–2025
- Stated actions
- 59
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
Failure to act on early warning scores
Miscalculation of early warning scores
This report raised 12 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 Critical Care outreach support and follow-up when elevated early warning scores are identified.
Stated by The Trust -
Action
Deliver the Trust-wide project and improvement measures to improve accurate acute monitoring using early warning scores.
Stated by The Trust -
Action
Pilot the revised Maternity Early Warning Scoring Chart and make necessary alterations before embedding it in practice.
Stated by The Trust
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Action
Introduce a newborn observation chart based on the British Association of Paediatric Medicine Newborn Early Warning Score.
Stated by The Trust
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Concerns raised1
Failure to recognise abnormal observations and escalate care
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.
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
Introduce an adapted Track and Trigger system across three prison healthcare teams and train staff to use it.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised2
Failure to ensure qualified checking and interpretation of Early Warning Observation Chart observations
Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care
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 refer patients to the Critical Care Outreach Team at required NEWS thresholds
This report raised 8 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 act on or escalate elevated Early Warning Scores
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Subjective interpretation of Early Warning Scores
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.2
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Action
Roll out Patientrack phase one across wards for electronic vital-sign input.
Stated by Stockport NHS Foundation Trust -
Action
Introduce Patientrack alert functionality in the planned second rollout phase.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure to escalate care after deteriorating neurological observations
This report raised 8 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 act on NEWS scores
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 raised3
Failure to contact a consultant when Early Warning Scores indicate clinical deterioration
Failure to refer patients to consultant level when Early Warning Scores indicate escalation
Lack of a single standardised Early Warning Score calculation system
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.
Data last updated 7 September 2026