First reported 28 Mar 2013•Latest report 24 Jun 2026
Definition
What this concern includes
Includes observation-level assessment, observation policies and support plans, staff allocation and reliable delivery of required intermittent or enhanced patient observations.
Not included
Condition-specific physiological or neurological monitoring
Management auditing of observations where frontline observation arrangements are otherwise reliable
Continuous eyesight or one-to-one observation where that dedicated control supplies a narrower parent
Reports
139
Distinct published reports
Individual concerns
174
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
328
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.
Care Quality Commission11
Department of Health and Social Care11
Essex Partnership University NHS Foundation Trust7
NHS England7
Sussex Partnership NHS Foundation Trust5
Devon Partnership NHS Trust4
East London NHS Foundation Trust4
HM Prison and Probation Service4
Greater Manchester Mental Health NHS Foundation Trust3
North London NHS Foundation Trust3
The Queen Elizabeth Hospital, King's Lynn3
University Hospitals Sussex NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Central and North West London NHS Foundation Trust2
County Durham and Darlington NHS Foundation Trust2
NHS trust92
Healthcare site16
Ministerial department12
Private limited company12
Health and social care service regulator11
Executive non-departmental public body7
Independent healthcare provider7
Police force7
Executive agency6
Nursing home6
Local health board4
Professional body4
Type not available4
Multi-service care provider3
English metropolitan district council2
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.
Worcestershire
Concerns raised1
Failure to carry out checks or observations on a deteriorating patient
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 concerns
Each 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.3
Action
Complete the commissioned case review to identify system improvements and examine its findings for wider learning.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2026.
Action
Update the discharge lounge SOP on patient capacity, deteriorating-patient management, and exclusion criteria for unsuitable patients.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 September 2026.
Action
Require the discharge lounge team to record full observations electronically and use SBAR escalation for deterioration or medical emergencies.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient was in the discharge lounge before transfer, not the PDU.
Stated by Worcestershire Acute Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised2
Use of inappropriate or untrained staff for enhanced observation
Insufficient trained staffing for enhanced observations of patients at risk of severe self-harm
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 concerns
Each 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
Action
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Action
Include enhanced supervision in mandatory training for staff providing enhanced supervision to patients.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No evidence was identified that Trust-employed security staff were allocated to patients that night, as would usually have been documented.
Stated by Mid and South Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Responsibility for mental health team staffing falls within Essex Partnership University Foundation Trust's remit, not this Trust's.
Stated by Mid and South Essex NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to conduct patient observations at scheduled times
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 concerns
Each 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
Action
Review observation competency compliance across substantive and temporary staff.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Reinforce requirements for observation training, competency assessment, and ward induction before staff undertake observation duties.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Monitor observation practice and documentation through audits, quality visits, safety huddles, senior reviews, and governance reporting.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Amend the supportive observations policy and observation form to require and record each patient’s exact observation time.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust did not endorse treating later observations as correcting missed observations; the information offered a possible explanation for the worker’s timing error.
Stated by North London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to provide appropriate observation in accordance with falls risk assessments and care plans
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 concerns
Each 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.3
Action
Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2026.
Action
Reinforce ward handovers remaining inside patient bays through daily safety-huddle reminders and stay-in-the-bay armbands, with compliance monitoring.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2026.
Action
Escalate staffing and patient-dependency pressures daily while reviewing ward establishment levels to address increased dependency.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 June 2026.
Inner South London
Concerns raised1
Failure to complete required patient 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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West London
Concerns raised2
Failure to attempt engagement during patient observations
Failure to conduct general hourly observations beyond a headcount
Responses linked to these concerns
Each 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.9
Action
Implement the revised Observation and Engagement Policy, including clarified expectations for general and intermittent observations and an agreed staff code of conduct.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Action
Deliver organisation-wide webinars launching the revised observation policy for substantive, bank and agency staff.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Action
Update observation e-learning and require staff to complete it alongside a new competency framework demonstrating understanding and compliance.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Action
Pilot digital recording of general and intermittent observations across six inpatient wards, supported by PDSA cycles and evaluation.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Action
Provide staff with credit-card-sized observation memory cards distinguishing observation levels and minimum engagement expectations.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2026.
Action
Implement mandatory competency-based observation assessments and reinforce staff roles, responsibilities and expectations through training and regular supervision.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
Action
Increase leadership oversight through regular ward visits to support safe observation practice and policy compliance.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2026.
Action
Create and deploy a dashboard showing the quality of observations to clinical staff.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
Action
Continue monitoring the effectiveness of observation improvements and embedding them into routine practice.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
General observations are intended to locate patients and visually check wellbeing, while meaningful engagement applies to intermittent observations.
Stated by South West London and St George'S Mental Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised3
Failure to maintain staff observation of the Oxevision monitor during WiFi disruption
Failure to conduct observations in accordance with Trust policy
Failure to provide required observations by trained staff
This report raised 28 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Implement electronic observations, staff training videos, engagement plans, and revised observation policies and procedures.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Retrain clinical staff in Oxevision and observation use in accordance with the relevant procedures and policy.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Implement staffing controls requiring appropriately skilled and inducted bank and agency staff, supported by rota review and competency oversight.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Implement patient-specific engagement and observation plans and maintain a maximum allocation of three level-two patients to one staff member in CAMHS.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Strengthen observation monitoring through nurse-in-charge checks, handover checks, compliance audits, escalation, and staff accountability processes.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing systems are considered robust enough to identify missed observations and ensure appropriate follow-up action with staff.
Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to reassess the frequency and quality of required observations
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Deliver mandatory refresher training on structured risk assessment, dynamic risk documentation and appropriate observation levels, with monthly compliance audits.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Cambridgeshire and Peterborough
Concerns raised1
Failure of the Close Observation Risk Assessment to clearly distinguish fall-related scoring factors
Responses linked to these concerns
Each 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
Action
Revise the Enhanced Care Risk Assessment Form to distinguish previous community falls from inpatient falls during the current admission.
Stated by North West Anglia NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Review the relevant Policy and Form within the next few months and take the coroner’s comments into account.
Stated by North West Anglia NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
West Yorkshire (Western)
Concerns raised2
Failure to document reasons for incomplete ward observations
Failure to complete ward observations in accordance with escalation guidance
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 concerns
Each 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.3
Action
Disseminate incident learning through ward safety huddles and the Sisters’ meeting.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Conduct weekly audits of patient observation charts and report the results to the Clinical Governance Committee.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
Action
Provide documented staff feedback and mandatory retraining on NEWS escalation requirements.
Stated by Bradford Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 October 2025.
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Includes observation-level assessment, observation policies and support plans, staff allocation and reliable delivery of required intermittent or enhanced patient observations.
