First reported 28 Mar 2013•Latest report 24 Jun 2026
Definition
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
Distinct published reports
Individual concerns
174
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
328
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.
Care Quality Commission11
Department of Health and Social Care11
Essex Partnership University NHS Foundation Trust7
NHS England7
Sussex Partnership NHS Foundation Trust5
Devon Partnership NHS Trust4
East London NHS Foundation Trust4
HM Prison and Probation Service4
Greater Manchester Mental Health NHS Foundation Trust3
North London NHS Foundation Trust3
The Queen Elizabeth Hospital, King's Lynn3
University Hospitals Sussex NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Central and North West London NHS Foundation Trust2
County Durham and Darlington NHS Foundation Trust2
NHS trust92
Healthcare site16
Ministerial department12
Private limited company12
Health and social care service regulator11
Executive non-departmental public body7
Independent healthcare provider7
Police force7
Executive agency6
Nursing home6
Local health board4
Professional body4
Type not available4
Multi-service care provider3
English metropolitan district council2
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.
Manchester South
Concerns raised1
Lack of staff understanding and prioritisation of the risk of leaving high-risk patients unobserved
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 concerns
Each 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
Action
Provide and publicise FallSafe training covering observation, inpatient-fall risk reduction and post-fall management.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Registered providers, rather than CQC, must determine how to implement detailed standards and good practice for patient safety.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Lack of close checks and observations for patients in the hospital discharge lounge
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised2
Failure to carry out prescribed patient observations
Failure to align observation frequency decisions with policy guidance
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Refresh observation training to make enhanced-observation requirements explicit and deliver it to relevant clinical staff.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Action
Share observation guidance and discuss it in ward safety huddles, meetings and supervision.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Action
Review the Safe and Supportive Observations Policy to clarify escalation when staffing or other constraints challenge observation provision.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
Action
Share the clarified observation-escalation process through leadership meetings, team meetings and individual supervision.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Action
Commission an independent review of the MDT clinical decision about observation frequency.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Safe and Supportive Observations Policy already prohibits suspending observations; the response limits further work to clarifying escalation.
Stated by North East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Essex
Concerns raised3
Lack of effective communication about required care, treatment and observation levels
Failure to reconsider observation levels after falls in light of physiotherapist advice
Confusing observation policy failing to address physical healthcare risks
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 concerns
Each 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
Action
Ensure physiotherapy input at daily safety huddles, including communication of observation requirements and risk-mitigation plans.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Display and maintain patient-bedroom mobility-assistance posters, updating and communicating them when mobility needs change.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Develop two standard operating procedures covering inpatient falls management and post-fall management.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Use clinical guidance and neurological observation charts to specify post-fall neurological assessment, Glasgow Coma Scale recording and observation frequencies.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Leicester City and South Leicestershire
Concerns raised1
Disconnect between observation policy, staff instructions and pre-printed recording forms
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 concerns
Each 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
Action
Replace hospital observation forms with two centralised forms used across all Inmind hospitals.
Stated by Inmind Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
Action
Update the Inmind Observations Policy to require centralised forms and compliance with national NHS standards.
Stated by Inmind Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
Action
Train HCAs and other staff to complete meaningful observation records, followed by competency assessment.
Stated by Inmind Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 31 January 2023.
Action
Carry out regular audits of observation-record quality across all Inmind hospitals, overseen by the Group Medical Director.
Stated by Inmind Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 January 2023.
Essex
Concerns raised1
Failure of risk assessments to capture key risk information before ward observation levels are reduced
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 concerns
Each 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.7
Action
Revise observation recording documentation and add observation-level decision and audit requirements to assurance audits.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Introduce an Engagement and Observation Plan recording observation commencement, review, changes and discontinuation against patient risk.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Implement an electronic clinical dashboard showing recent clinical entries, current risk assessments and observation levels at handover.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Review the Trustwide Engagement and Supportive Observation Procedure to require MDT decisions informed by comprehensive risk assessment and documented care-plan rationale.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Configure risk-assessment documentation in Paris and Mobius to carry forward risk history while capturing newly identified risks.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Continue observation assurance monitoring through Tendable and observation-engagement audits, with weekly review of findings by the Inpatient Clinical Support Group.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Action
Continue the adult inpatient record-keeping clinical audit covering current risk assessments, risk-management plans, MDT input, observation care plans and crisis plans.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Liverpool and the Wirral
Concerns raised2
Ward layout failing to support easy observation of vulnerable patients
Insufficient staffing levels for informal observation, oversight and monitoring
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 concerns
Each 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
Action
Reconfigure the ward as a 20-bed facility to improve patient observation and oversight.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 October 2022.
Action
Relocate the ligature knife and position nurse stations within ward corridor areas to support appropriate observations.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staffing is adjusted for the ward environment, patient acuity and individual needs, so further staffing changes are not indicated.
Stated by Cheshire and Wirral Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Limited risk reduction from observation frequency for high-risk patients
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 concerns
Each 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
Action
Review national risk-assessment guidance and assess moving to an evidence-based, personalised safety-planning approach.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 October 2022.
Norfolk
Concerns raised1
Failure to carry out observations in accordance with policy
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Deliver ward-specific Safety Day training on clinical risk, care planning, incident learning and therapeutic observations.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
Action
Refresh staff understanding of the therapeutic observations policy through competency reassessment.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
Action
Share learning from the inquest with ward staff through a scheduled Registered Nurses Day.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Action
Review the Therapeutic Observations Policy to consider strengthened training, documentation, ward controls, staff guidance and assurance processes.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2022.
Action
Strengthen the therapeutic-observations policy guidance on entering rooms during immediate welfare concerns and seeking help for staff safety.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
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Includes observation-level assessment, observation policies and support plans, staff allocation and reliable delivery of required intermittent or enhanced patient observations.
