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
Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation
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.5
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Action
Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Provide EPUT input and support to MSE’s ratification of its acute-hospital mental health admission and treatment policy.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Improve the enhanced supervision policy with practical guidance for safely supporting patients awaiting Mental Health Act assessment.
Stated by Mid and South Essex NHS Foundation Trust
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Action
Deliver nursing training on the updated supervision policy and record-keeping standards for supervision documentation.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Rewrite enhanced-supervision criteria to clarify when patients awaiting assessment should receive enhanced supervision.
Stated by Mid and South Essex 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
The Acute Trust is responsible for responding to concerns about the regime and policy for one-to-one observation pending Mental Health Act assessment.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to undertake adequate physical-health observations for highly agitated patients
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.
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 complete scheduled 7am support-plan checks
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.
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
Ash showed no behaviours or indicators requiring early-hours checks on 7 August 2021.
Stated by United Children's Services (United Health
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Concerns raised1
Lack of adequate staff training and understanding of the level two observations policy
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.
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
Implement revised observation policy with clearer level 2 guidance, irregular intervals, multidisciplinary decisions and dedicated staffing for high-frequency observations.
Stated by Somerset NHS Foundation Trust -
Action
Require and monitor competence assessment, supervised observation rounds and suicide-prevention training for all staff undertaking observations, including bank and agency staff.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Failure by healthcare staff to carry out adequate observations
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
Implement an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
Stated by HM Prison and Probation Service
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Concerns raised1
Inadequate arrangements for managing and implementing intermittent observation
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.4
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Action
Use twice-daily electronic SBAR updates and structured staff handovers, including daily safety reporting, to communicate safety-critical information.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Apply observation competency checks, prompt sheets, nurse-in-charge oversight and monthly supportive-observation audits on Victoria Ward.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Test and evaluate the digital supportive-observation and therapeutic-engagement recording solution before deciding on wider rollout.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Action
Implement recommendations from the national therapeutic-observation and engagement review.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Failure to use Oxevision only as an adjunct to face-to-face 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.4
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Action
Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Circulate and reinforce the Therapeutic Engagement and Supportive Observation policy across all wards.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Lack of clarity over responsibility for feedback on observation chart problems
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
Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.
Stated by Devon Partnership NHS Trust
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Concerns raised1
Failure to take observations hourly
This report raised 7 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 undertake observations following changes in patient presentation
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.3
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Action
Amend the INR point-of-care-testing SOP and training video to cover anticoagulant-related bleeding complications and prompt observations after clinical deterioration.
Stated by Cornwall Partnership NHS Foundation Trust -
Action
Obtain investment for additional CASP training capacity and deliver three to four extra sessions annually for registered community nurses.
Stated by Cornwall Partnership NHS Foundation Trust -
Action
Develop and share a learning-from-experience poster with community nursing teams on observations, deterioration recognition and documentation.
Stated by Cornwall Partnership NHS Foundation Trust
Data last updated 7 September 2026