Recurring concern

Unreliable escalation of abnormal clinical observations

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First reported 24 Sep 2013•Latest report 17 Nov 2025

Definition

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

Distinct published reports

Individual concerns
44

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
59

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.

Department of Health and Social Care7
Care Quality Commission3
NHS England3
University Hospitals Sussex NHS Foundation Trust3
Pennine Acute Hospitals NHS Trust2
Royal College of Paediatrics and Child Health2
Royal Sussex County Hospital2
Swansea Bay University Local Health Board2
A & B Healthcare Limited1
Aneurin Bevan University LHB1
Barts Health NHS Trust1
Bedfordshire Hospitals NHS Foundation Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Bristol NHS Foundation Trust1

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.

  1. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · 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

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    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

    Delays in escalating NEWS to medical staff

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. Avon

    AI-generated summary

    Graham William FOX · 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

    Graham William FOX was admitted to hospital after a fall in the community in which he broke both ankles. His condition deteriorated, but NEWS assessment and referral were not correctly implemented overnight, and he was not seen by a doctor as he should have been; he was admitted to the Critical Care Unit the following morning and subsequently died. Concerns included misunderstanding among some nursing staff about whether NEWS responses were mandatory and the use of “re-triggering” under NEWS without expert evidence about its clinical appropriateness.

    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 ensure consistent understanding that NEWS-triggered clinical responses are mandatory

    Wider context from the report

    “(1) The standard NEWS documentation contains a list of scores on the left, and corresponding clinical responses in a column on the right. My understanding of the system was that when the relevant score was reached, the corresponding clinical response was mandatory. The impression I gained from listening to the majority of the nursing staff was that there was an element of discretion / clinical judgment to be applied in determining whether the clinical responses that were ‘required’ when the relevant score was reached were actually necessary. The more senior nursing staff were clear that the relevant responses were mandatory, but that was not the impression given by the more junior staff. This evidence (which gave the impression that staff discretion could be applied to the clinical responses) was given after the staff had, apparently, been given additional NEWS training following Mr Fox’s death. ”

    Source location

    Graham William FOX · 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

    Operate electronic observations that calculate NEWS, prompt timely repeat observations, and trigger escalation under the Trust protocol.

    Verbatim wording from the response

    “Since this incident the Trust has implemented an e-observations system in our adult in-patient wards whereby the patient's physiological measurements are entered electronically into a hand held device, which automatically calculates the national early warning score (NEWS) and prompts the staff member to repeat the observations in the required timeframe and to escalate to the relevant clinician in accordance with the Trust's escalation protocol.”

    Source location

    2018-0192-Response-by-University-Hospitals-Bristol-NHS-Trust
    Page 1 · response
    Published 9 July 2018

    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

    Implement CareFlow to automate escalation notifications to the relevant doctor or senior nurse under the escalation protocol.

    Verbatim wording from the response

    “At present, such escalation is completed by telephone or in person, but we will shortly be implementing a further clinical communications system (“CareFlow”) whereby the escalation will be automated to the relevant doctor or senior nurse in accordance with the escalation protocol. The CareFlow system is currently being used in a few areas for some elements of clinical communication.”

    Source location

    2018-0192-Response-by-University-Hospitals-Bristol-NHS-Trust
    Page 2 · response
    Published 9 July 2018

    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

    Deliver training and education on revised escalation alongside implementation of the electronic observations system.

    Verbatim wording from the response

    “We have been supporting the implementation of the e-observations with a further programme of training and education on revised escalation and will continue to do so as we switch to the new national early warning score (NEWS2) planned for October 2018.”

    Source location

    2018-0192-Response-by-University-Hospitals-Bristol-NHS-Trust
    Page 2 · response
    Published 9 July 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

    Documented revised escalation plans are considered appropriate after clinical review where defined conditions are met, rather than requiring automatic re-triggering.

    Verbatim wording from the response

    “With regards to the practice of “re-triggering”, this perhaps should be more accurately referred to as “revised escalation” and we have been promoting this terminology within the Trust since we commenced implementing the e-observations system towards the end of 2017. Some patients do have elevated early warning scores due to a long term condition which is “normal for them”; in these situations it can be appropriate for a doctor to document a clear revised escalation plan setting out the circumstances an escalation should be enacted.”

    Source location

    2018-0192-Response-by-University-Hospitals-Bristol-NHS-Trust
    Page 2 · response
    Published 9 July 2018

    Open published response

  3. Sunderland

    AI-generated summary

    Patricia Ann Heslop · 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

    Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

    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 an effective observation-based early warning system

    Wider context from the report

    “3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations. ”

    Source location

    Patricia Ann Heslop · 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

    Train nurses and senior care staff in the NEWS early-warning system and deliver the training to care staff.

    Verbatim wording from the response

    “3.2 Evidence was heard during the inquest of the increased use of NEWS early warning system to enable observations to be obtained. NEWS is a well validated ‘track and trigger’ early warning score system used in the majority of UK hospitals. It is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present or are being monitored in healthcare settings. Use of NEWS score assist in the identification of a sick patient. Evidence was provided that staff at Hebburn Court have now been trained in the NEWS system. All nurses and senior care staff have received training in the system and this will also then be delivered to care staff over the coming few months.”

    Source location

    2018-0102-Response-by-HC-One
    Page 5 · response
    Published 17 June 2018

    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

    Embed Resident of the Day quality-assurance reviews to identify changes or deterioration and monitor care and support needs.

    Verbatim wording from the response

    “6.1 Evidence was heard during the inquest that the delay in obtaining treatment, whilst did not directly contribute to the death, did result in Mrs. Heslop being in pain for a longer period than necessary. This can be attributed to by carers and nursing staff not appropriately recognising and acting upon indicators of deterioration. The Resident of the Day reviews identify any changes or deterioration now that the quality assurance system has been reset and embedded at the home. This will be further enhanced by the e.care system, as mentioned previously in terms of robust monitoring and reviews of care and support needs.”

    Source location

    2018-0102-Response-by-HC-One
    Page 7 · response
    Published 17 June 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

    Terminological differences cannot all be removed and are not necessarily inappropriate, although consistent language and indicators are important.

    Verbatim wording from the response

    “3.1 You identified that a number of terms were used regarding Mrs. Heslop’s developing condition. ████████ provided evidence during the inquest that whilst it is not possible to remove all differences in clinical description (including the use of colloquialisms and staff language) to describe a resident's individual presentation nor is it necessarily appropriate to do so, it is however important to provide consistent language and indicators which can provide an early warning system based on observations.”

    Source location

    2018-0102-Response-by-HC-One
    Page 5 · response
    Published 17 June 2018

    Open published response

  4. South Wales Central

    AI-generated summary

    Hedley Greenland · 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

    Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.

    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 recognise and escalate absent urine output

    Wider context from the report

    “(1) A fluid balance chart should have been used by nursing staff to monitor fluid intake and urine output. There was no evidence that one had been thus rendering it impossible to measure urine output which might have indicated a blockage and/or infection. It was apparent during the course of the evidence that the nurse in charge of Mr Greenland's care did not consider actively monitoring his urine output, neither did she consider flushing the catheter. There was no written handover, as the evidence showed is normally the practice, to the incoming nursing team the following morning. There was no clear evidence that the lack of urine output had been noted by the night shift with a view to escalating his care. The evidence revealed that there was no urine output for at least 9 hours but probably substantially more than that. ”

    Source location

    Hedley Greenland · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. South Wales Central

    AI-generated summary

    Dennis George Redmore · 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

    Dennis George Redmore was admitted to hospital with a blocked catheter and presumed urinary tract infection while receiving palliative treatment for lymphoma. After an unwitnessed fall in hospital on 6 March 2017, he deteriorated, was found to have a subdural haematoma, and died later the following evening. The report identified gaps in neurological observations, delayed response to abnormal observations, and inadequate management to ensure checks were completed; it did not establish that these failures caused or contributed to his death.

    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

    Delay in acting on abnormal NEWS observations

    Wider context from the report

    “(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50. “NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded. The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others. No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out. ”

    Source location

    Dennis George Redmore · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. London (West)

    AI-generated summary

    Alice Amaryllis Gibson-Watt (“Alice”) · 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

    Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

    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 accurately interpret and act upon abnormal observations

    Wider context from the report

    “This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. I am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. I am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have seen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ”

    Source location

    Alice Amaryllis Gibson-Watt (“Alice”) · Prevention of Future Deaths report
    Page 3 · 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

    Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.

    Verbatim wording from the response

    “• In parallel, NHS England continues to support the ongoing inspection and regulation of mental health in-patient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS.”

    Source location

    2017-0163-Response-by-NHS-England
    Page 2 · response
    Published 17 August 2017

    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

    Health Education England is responsible for ensuring mental health staff have appropriate skills and competence for physical healthcare roles.

    Verbatim wording from the response

    “• Whilst NHS England does not mandate which specific job roles should deliver which elements of the physical health care agenda in mental health settings, staff should be competent with the appropriate training and ongoing CPD to meet the full needs of patients. Health Education England (HEE) ensures that all members of the mental health team are appropriately skilled and competent to perform their roles and responsibilities in addressing the physical health needs of their service users.”

    Source location

    2017-0163-Response-by-NHS-England
    Page 2 · response
    Published 17 August 2017

    Open published response

  7. Manchester City

    AI-generated summary

    Name not published · 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

    A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.

    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 neurological or general observations appropriately

    Wider context from the report

    “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  8. South Wales Central

    AI-generated summary

    Harold Mullins · 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

    Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

    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 appropriately escalate care in response to deteriorating NEWS scores

    Wider context from the report

    “(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”

    Source location

    Harold Mullins · 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

    Delays in clinical review of patients with deteriorating NEWS scores

    Wider context from the report

    “(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”

    Source location

    Harold Mullins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester City

    AI-generated summary

    Mrs Kathleen Cooper · 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

    Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

    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

    Incorrect calculation of early warning scores

    Wider context from the report

    “3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”

    Source location

    Mrs Kathleen Cooper · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Blackpool and the Fylde

    AI-generated summary

    Barry THOMPSON · 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

    Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

    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 act on elevated National Early Warning Scores

    Wider context from the report

    “(1) Non-compliance with National and Local protocols: Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately. ”

    Source location

    Barry THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026