Recurring concern
Unreliable patient observation arrangements
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Request correctionFirst reported 28 Mar 2013•Latest report 24 Jun 2026
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
- Individual concerns
- 174
- Date range
- 2013–2026
- Stated actions
- 328
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
Lack of clear and consistent drug-related risk assessment and observation 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 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 raised2
Failure to carry out required observations
Failure to conduct observations at varied times
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 of ward policy to require unpredictable and irregular observations
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.1
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Action
Finalize and implement revised Engagement Policy requirements for documenting and varying intermittent engagement and observation intervals.
Stated by Devon Partnership NHS Trust
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Concerns raised1
Inadequate observations under ACCT plans
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.
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
Deliver local ACCT refresher training to 48 staff on 13 and 20 December 2016, then provide it at least monthly.
Stated by HM Prison and Probation Service -
Action
Recruit and deploy 12 new Prison Officers who complete entry-level training covering suicide, self-harm awareness and the ACCT process.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to increase observation frequency during clinical deterioration
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.
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 maintain required 15-minute observation of residents
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to follow the Therapeutic Engagement and Observation Policy and escalate observation levels when required
Lack of automatic escalation of observation levels after serious events placing patients at risk of immediate or imminent harm
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.3
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Action
Update the Therapeutic Engagement and Observation Policy to require automatic escalation of observations after serious self-harm pending full MDT review.
Stated by Betsi Cadwaladr University LHB -
Action
Integrate compliance auditing into the divisional audit cycle and report outcomes and improvement suggestions through divisional governance to QSE.
Stated by Betsi Cadwaladr University LHB -
Action
Hold a learning event and formally relaunch the updated policy at the event.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to carry out hospital observation checks correctly and ensure patient safety
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.6
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Action
Conduct monthly checks of observation windows on every ward and record and escalate damage.
Stated by West London NHS Trust -
Action
Conduct unannounced out-of-hours audits of observation practice.
Stated by West London NHS Trust -
Action
Deliver mandatory clinical risk training on engagement and supportive observations to clinical staff every three years.
Stated by West London NHS Trust
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Action
Maintain ward-level knowledge and skills assessments for staff undertaking enhanced engagement and observations, with annual auditing.
Stated by West London NHS Trust -
Action
Deliver local and national workshops focused on observation practice.
Stated by West London NHS Trust -
Action
Participate in a cross-hospital CQUIN programme on best practice in managing risk through supportive observations.
Stated by West London NHS Trust
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Concerns raised2
Failure to conduct Level 2 observations at prescribed intervals
Failure to carry out Level 2 observations in accordance with protocol
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.3
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Action
Implement the Therapeutic Observation Policy with competency-based training and competency checks before staff lead patient observations.
Stated by Leicestershire Partnership NHS Trust -
Action
Report missed observations through the incident system, review them by the ward matron, and interview responsible staff with action taken where necessary.
Stated by Leicestershire Partnership NHS Trust -
Action
Review the Therapeutic Observation Policy to determine how physical-health observations should be incorporated or separately guided.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Failure of staff to understand required patient-observation practices
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.2
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Action
Review and update the Observation and Engagement of Service Users policy to clarify additional-observation requirements.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Communicate updated observation requirements through staff emails, the Patient Safety Newsletter, and governance and leadership forums.
Stated by Norfolk and Suffolk NHS Foundation Trust
Data last updated 7 September 2026