Recurring concern
Unreliable patient observation arrangements
- Reports that mention this concern
- 139
- Times this concern has been raised
- 174
- Stated actions linked to this concern
- 328
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.
What is 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
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 139 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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.
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.
Linked response
- Devon Partnership NHS Trust
Stated actions 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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Devon Partnership NHS Trust
Finalize and implement revised Engagement Policy requirements for documenting and varying intermittent engagement and observation intervals.
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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.
Linked response
- HM Prison and Probation Service
Stated actions 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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HM Prison and Probation Service
Deliver local ACCT refresher training to 48 staff on 13 and 20 December 2016, then provide it at least monthly.
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HM Prison and Probation Service
Recruit and deploy 12 new Prison Officers who complete entry-level training covering suicide, self-harm awareness and the ACCT process.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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
Linked response
- Betsi Cadwaladr University LHB
Stated actions 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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Betsi Cadwaladr University LHB
Update the Therapeutic Engagement and Observation Policy to require automatic escalation of observations after serious self-harm pending full MDT review.
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Betsi Cadwaladr University LHB
Integrate compliance auditing into the divisional audit cycle and report outcomes and improvement suggestions through divisional governance to QSE.
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Betsi Cadwaladr University LHB
Hold a learning event and formally relaunch the updated policy at the event.
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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.
Linked response
- West London NHS Trust
Stated actions 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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West London NHS Trust
Conduct monthly checks of observation windows on every ward and record and escalate damage.
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West London NHS Trust
Conduct unannounced out-of-hours audits of observation practice.
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West London NHS Trust
Deliver mandatory clinical risk training on engagement and supportive observations to clinical staff every three years.
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West London NHS Trust
Maintain ward-level knowledge and skills assessments for staff undertaking enhanced engagement and observations, with annual auditing.
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West London NHS Trust
Deliver local and national workshops focused on observation practice.
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West London NHS Trust
Participate in a cross-hospital CQUIN programme on best practice in managing risk through supportive observations.
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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.
Linked response
- Leicestershire Partnership NHS Trust
Stated actions 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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Leicestershire Partnership NHS Trust
Implement the Therapeutic Observation Policy with competency-based training and competency checks before staff lead patient observations.
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Leicestershire Partnership NHS Trust
Report missed observations through the incident system, review them by the ward matron, and interview responsible staff with action taken where necessary.
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Leicestershire Partnership NHS Trust
Review the Therapeutic Observation Policy to determine how physical-health observations should be incorporated or separately guided.
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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.
Linked response
- Norfolk and Suffolk NHS Foundation Trust
Stated actions 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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Norfolk and Suffolk NHS Foundation Trust
Review and update the Observation and Engagement of Service Users policy to clarify additional-observation requirements.
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Norfolk and Suffolk NHS Foundation Trust
Communicate updated observation requirements through staff emails, the Patient Safety Newsletter, and governance and leadership forums.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026