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
Failure to undertake observations of sufficient quality
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Documentation, observations, vulnerability assessment, COVID-19 transmission, and ambulance delay were outside the respondent’s remit, control, and responsibility.
Stated by Public Health EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Other named organisations, including the care home, regulators, NHS England, and the local partnership, were responsible for commenting on remaining concerns.
Stated by Public Health EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing post-fall and illness-management processes address the known risks, including appropriate observations, medical support and documentation.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to observe patients in the garden unless eyesight observations are required
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.1
Action
Remove the lower portion of the day-room window film to improve visibility into the garden while retaining upper-level privacy screening.
Stated by Midlands Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 December 2020.
Manchester South
Concerns raised2
Failure to perform clinical observations at appropriate frequency for sick patients
Failure to produce a protocol for the frequency of observations in sick 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 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.3
Action
Speak to staff involved and remind them to record and escalate observations appropriately and promptly.
Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2020.
Action
Deliver ward training on observation recording and escalation under Trust policies and procedures.
Stated by Stockport NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2020.
Action
Produce daily NEWS2 reports for Matrons and Ward Managers and review whether appropriate action has been taken.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Black Country
Concerns raised1
Failure to document increased observation arrangements in written records or care plans
This report raised 12 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.
Inner North London
Concerns raised1
Failure to monitor patients in communal areas
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.2
Action
Increase staffing and senior oversight on each floor by adding senior managers and team-leader walkarounds.
Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
Action
Implement daytime documented welfare checks and audit completion through the Home Manager’s daily random documentation checks.
Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The incident occurred on arrival at Muriel Street, not during hospital readmission, and the resident was neither in public nor unresponsive.
Stated by Care UK Community Partnerships LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Derby and Derbyshire
Concerns raised1
Lack of formal policies for observing residents
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 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.
Manchester West
Concerns raised4
Failure of investigation staff to correctly understand and apply the observation policy
Failure of ward management to understand the observation policy
Failure to carry out patient observations at irregular intervals within the permitted time window
Failure of ward supervision to check compliance with the observation 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 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.8
Action
Develop standard serious-incident-investigation terms of reference requiring assessment against evidence-based practice, NICE guidance, policies and procedures.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
Action
Develop a refresher training package on therapeutic observations, including policy procedures and clinical case studies.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
Action
Support the Deputy Ward Manager’s ongoing policy-compliance reflection and quality-assurance responsibilities through ward-manager supervision.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2020.
Action
Deliver face-to-face refresher training on observation and engagement policy, including delayed record-keeping requirements, to nursing staff and healthcare assistants.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
Action
Communicate learning from the death and the requirement to stagger therapeutic-observation checks to nursing staff and healthcare assistants.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2020.
Action
Introduce electronic observations to record exact observation times in electronic care records.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
Action
Audit electronic observation records monthly and discuss results at the local quality, safety and safeguarding group.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2020.
Action
Conduct regular ward audits of compliance with the observation policy and report findings to the Borough senior leadership team.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2020.
Black Country
Concerns raised1
Failure to adhere to the five-minute patient observation level
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised2
Failure to perform required patient observations
Failure to conduct timely and adequate observations of patients whose condition is uncertain
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
Conduct ongoing investigations into concerns arising from the case.
Stated by NHS Professionals LimitedStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2019.
Action
Include evidence of completed and updated observation competency assessments in the whole-systems review actions.
Stated by NHS Professionals LimitedStated plannedThe respondent said that this action was planned when they made their response on 6 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Client Trusts deliver substantive staff training, and ward staff undertake competency assessments before nurses perform observations.
Stated by NHS Professionals LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Buckinghamshire
Concerns raised1
Variation in the timing and conduct of hourly patient observations
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.2
Action
Review and revise the Safe and Supportive Observations policy to improve the safety and effectiveness of observation practices.
Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Action
Implement and evaluate new approaches to enhanced observations through a quality improvement project.
Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Pin
Get email alerts
Request correction
Includes observation-level assessment, observation policies and support plans, staff allocation and reliable delivery of required intermittent or enhanced patient observations.
