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
Inadequate observation of patients in the healthcare unit
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.1
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Action
Remove CCTV cameras from healthcare-unit cells and use constant-observation cells with constant supervision for prisoners requiring high observation.
Stated by HM Prison and Probation Service and Holme House Prison
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Concerns raised3
Sporadic and insufficient physical observations
Unclear responsibility for stopping physical observations
Unclear policy on the duration of patient 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 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
Introduce enhanced physical-health monitoring, including daily morning observations for every patient by a trained nurse.
Stated by Partnerships in Care Group Limited -
Action
Introduce a company-wide electronic dashboard to support completion of regular physical-health screening.
Stated by Partnerships in Care Group Limited -
Action
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
Stated by Partnerships in Care Group Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Blood-pressure observations were neither sporadic nor few, and the available evidence indicates they continued during the final two days.
Stated by Partnerships in Care Group Limited
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Position
Any enhanced physical observations or ECG testing was expected to be ordered by the visiting GP or responsible Consultant Psychiatrist.
Stated by Partnerships in Care Group Limited
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Concerns raised1
Failure to perform basic nursing observations
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.6
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Action
Conduct an unannounced follow-up inspection assessing emergency procedures, observation policies, staff training and completion of earlier compliance actions.
Stated by Care Quality Commission -
Action
Assess observation training and continue monitoring observation information and policy implementation to inform future inspections.
Stated by Care Quality Commission -
Action
Undertake an unannounced inspection within four months covering reported concerns, additional regulatory concerns and new intelligence, coordinated with Mental Health Act monitoring.
Stated by Care Quality Commission
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Action
Change the Roehampton staff induction programme to improve compliance with patient observations.
Stated by Priory Group -
Action
Review the Priory Healthcare Division Observation and Engagement Policy.
Stated by Priory Group -
Action
Conduct weekly four-week-cycle Quality Walk Rounds, including checks of patient observations and care plans, with results reviewed through clinical governance.
Stated by Priory Group
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Concerns raised1
Failure to carry out required clinical and nursing observations
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 raised1
Insufficient frequency of nursing observations for uncleared patients
This report raised 9 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 take hourly nursing observations in A&E
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.1
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Action
Remind nursing staff to complete and accurately record patient observations.
Stated by South Tees Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Trust policy considered the Early Warning Score insufficient to require medical review, so observation levels and frequency were managed under existing arrangements.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised1
Unavailability of alarms for high-risk patients requiring monitoring during mobilisation
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 document the rationale and risk factors underlying changes in observation levels
Failure to align observation levels with changing suicidal risk
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.1
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Action
Provide staff training on consistently documenting the rationale for changes in observation levels.
Stated by Sussex Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Observation rationale need not be recorded when levels remain unchanged unless clinical staff identify a significant risk change.
Stated by Sussex Partnership NHS Foundation Trust
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Position
Clinicians did not consider a different observation level clinically indicated based on information available at the time.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised2
Failure to check whether patients have moved or remained immobile for an extended period during hourly observations
Lack of continuity among staff undertaking observations of individual patients
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