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
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.
Linked responses
- HM Prison and Probation Service
- Holme House Prison
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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HM Prison and Probation Service and Holme House Prison
Remove CCTV cameras from healthcare-unit cells and use constant-observation cells with constant supervision for prisoners requiring high observation.
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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.
Linked response
- Partnerships in Care Group Limited
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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Partnerships in Care Group Limited
Introduce enhanced physical-health monitoring, including daily morning observations for every patient by a trained nurse.
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Partnerships in Care Group Limited
Introduce a company-wide electronic dashboard to support completion of regular physical-health screening.
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Partnerships in Care Group Limited
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
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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Partnerships in Care Group Limited
Blood-pressure observations were neither sporadic nor few, and the available evidence indicates they continued during the final two days.
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Partnerships in Care Group Limited
Any enhanced physical observations or ECG testing was expected to be ordered by the visiting GP or responsible Consultant Psychiatrist.
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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.
Linked responses
- Care Quality Commission
- Priory Group
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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Care Quality Commission
Conduct an unannounced follow-up inspection assessing emergency procedures, observation policies, staff training and completion of earlier compliance actions.
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Care Quality Commission
Assess observation training and continue monitoring observation information and policy implementation to inform future inspections.
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Care Quality Commission
Undertake an unannounced inspection within four months covering reported concerns, additional regulatory concerns and new intelligence, coordinated with Mental Health Act monitoring.
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Priory Group
Change the Roehampton staff induction programme to improve compliance with patient observations.
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Priory Group
Review the Priory Healthcare Division Observation and Engagement Policy.
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Priory Group
Conduct weekly four-week-cycle Quality Walk Rounds, including checks of patient observations and care plans, with results reviewed through clinical governance.
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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.
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.
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.
Linked response
- South Tees Hospitals 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.1
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South Tees Hospitals NHS Foundation Trust
Remind nursing staff to complete and accurately record patient observations.
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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South Tees Hospitals NHS Foundation Trust
Trust policy considered the Early Warning Score insufficient to require medical review, so observation levels and frequency were managed under existing arrangements.
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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.
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.
Linked response
- Sussex Partnership 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.1
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Sussex Partnership NHS Foundation Trust
Provide staff training on consistently documenting the rationale for changes in observation levels.
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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Sussex Partnership NHS Foundation Trust
Observation rationale need not be recorded when levels remain unchanged unless clinical staff identify a significant risk change.
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Sussex Partnership NHS Foundation Trust
Clinicians did not consider a different observation level clinically indicated based on information available at the time.
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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
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026