First reported 10 Jan 2014•Latest report 3 Jun 2026
Definition
What this concern includes
Includes failures of controls specifically dedicated to recognising, assessing, escalating or responding to significantly abnormal blood pressure, including inaccurate severity assessment, failure to trigger medical review and failure to take appropriate action when abnormal blood pressure is known.
Not included
Excludes generic clinical assessment, escalation or staffing deficiencies that are not specifically tied to abnormal blood pressure.
Excludes unrelated abnormal observations, such as elevated NEWS scores, unless the asserted unsafe condition materially concerns blood-pressure recognition or response.
Excludes low or high blood pressure as a factual finding without an identified failure in its assessment, escalation or management.
Excludes downstream treatment failures where blood-pressure recognition and response were adequate.
Reports
10
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
22
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.
Department of Health and Social Care2
Nursing and Midwifery Council2
Association of Ambulance Chief Executives1
Belmarsh Prison1
Blackpool Teaching Hospitals NHS Foundation Trust1
Calderdale and Huddersfield NHS Foundation Trust1
Care Quality Commission1
East London NHS Foundation Trust1
East Suffolk and North Essex NHS Foundation Trust1
Faculty of Sexual and Reproductive Healthcare1
General Medical Council1
Lathom Road Medical Centre1
Luton and Dunstable University Hospital1
Luton and Dunstable University Hospital NHS Foundation Trust1
NHS England1
NHS trust8
Health and care professional regulator2
Healthcare site2
Ministerial department2
Executive non-departmental public body1
Health and social care service regulator1
Health professional body1
Health-sector membership body1
Nursing-home operator1
Prison or young offender institution1
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.
Devon, Plymouth and Torbay
Concerns raised1
Unclear interpretation of blood pressure in suspected aortic dissection
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
Amend hypotension wording to clarify the relevance of high and low blood pressure.
Stated by Association of Ambulance Chief ExecutivesStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026.
Essex
Concerns raised1
Failure to investigate the underlying cause of persistent tachycardia and low blood pressure
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 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
Discuss the case with ward and governance staff to promote recognition of underlying causes of abnormalities in apparently stable patients.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2024.
Action
Circulate learning on persistent tachycardia and the need for further investigations to identify its underlying cause.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised2
Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations
Failure to make further attempts to assess an unrecordable blood pressure
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.2
Action
Deliver manual blood-pressure training and competency assessment for Emergency Department staff, including escalation and alternative perfusion assessment methods.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
Action
Continue working with NHS England to identify resources needed for healthcare professionals to recognise and respond appropriately to patient deterioration.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust is responsible for responding directly to concerns about assessing the patient’s low blood pressure.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Failure to escalate episodes of raised blood pressure for medical review
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
Train staff on NEWS2 blood-pressure updates and revise NEWS2 scoring and recording templates in RiO.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Enable automatic RiO alerts for physical-health observations outside expected limits, including action guidance.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Action
Provide Cazaubon Ward staff training on elevated blood-pressure assessment and repeat measurement.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
Inner North London
Concerns raised2
Failure to record significantly elevated blood pressure readings in the medical record
Failure to bring significantly elevated blood pressure readings to the responsible clinician’s attention
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.5
Action
Place a sign above the blood-pressure machine directing patients to give their readings to reception.
Stated by Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Maintain staff vigilance to ensure patients using the machine submit their readings before leaving.
Stated by Lathom Road Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2022.
Action
Relocate the blood-pressure machine to the opposite reception-area wall to improve staff oversight while preserving confidentiality.
Stated by Lathom Road Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
Action
Implement a reception blood-pressure monitoring protocol covering receptionist duties, doctor notification and abnormal readings.
Stated by Partners, Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Maintain receptionist vigilance and, where possible, supervise patients using the monitor to ensure readings reach the doctor.
Stated by Partners, Lathom Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Continuous staff supervision of every patient using the blood pressure machine is not always possible because reception staff are already occupied with front-desk duties.
Stated by Lathom Road Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Receptionist supervision of blood pressure monitoring may not be possible during short staffing or busy periods.
Stated by Partners, Lathom Road Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire (Western)
Concerns raised2
Failure to accurately assess significantly elevated blood pressure
Lack of awareness of recommended treatment for elevated blood pressure in labour
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.
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 compulsory annual training for midwives and maternity staff covering CTG monitoring, maternal monitoring and obstetric emergencies.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 March 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The doctor’s reflection, assessment, training, subsequent practice and case reviews are considered sufficient to establish competency in managing obstetric emergencies and related concerns.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Blackpool and the Fylde
Concerns raised1
Failure to follow the review process after a marked blood pressure drop
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 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
Deliver deteriorating-patient simulation training for Emergency Department staff using Trust pathways and NEWS2 escalation algorithms.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2020.
Action
Establish the Deteriorating Patient Collaborative to test safer recognition and response to clinical deterioration.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2020.
Action
Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 December 2020.
Action
Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2020.
Inner South London
Concerns raised4
Failure to communicate and define reporting parameters for pre-administration blood-pressure readings
Failure to review blood-pressure trends before controlled-drug administration
Failure to suspend controlled drugs and escalate low blood pressure
Lack of defined criteria and recording requirements for lowering blood pressure
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Bedfordshire and Luton
Concerns raised1
Failure of staff to recognise an un-recordable blood pressure as a medical emergency requiring a crash call
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
Pilot a revised observation and escalation process, with registered nurses observing patients requiring observations more frequently than every four hours.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
Action
Emphasise Medical Emergency Team availability during mandatory basic life support training for all staff groups.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
Action
Evaluate current nurse and doctor training on identifying deteriorating patients and develop an improvement proposal informed by cardiac-arrest learning.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing cardiac-arrest protocols, medical-emergency procedures and mandatory training are considered sufficient arrangements for activating the appropriate response.
Stated by The TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Coventry
Concerns raised1
Failure of nursing home staff to take appropriate action when aware of low blood pressure
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls specifically dedicated to recognising, assessing, escalating or responding to significantly abnormal blood pressure, including inaccurate severity assessment, failure to trigger medical review and failure to take appropriate action when abnormal blood pressure is known.
