Recurring concern

Inadequate physical nursing care for vulnerable patients

First to latest report 13 Jan 2014 — 24 Apr 2026

Reports that mention this concern: 12
Times this concern has been raised: 12
Stated actions linked to this concern: 14

What this concern includes

Includes failures in the delivery and safety controls of physical nursing care for vulnerable patients, including clinical observation and NEWS recording or response, oxygen administration, recognition of physical illness, nursing treatment, escalation and related competence or supervision where these directly impair physical care.

What is not included

Excludes generic communication, record-keeping, staffing or training deficiencies unless they directly result in inadequate physical nursing care for vulnerable patients.
Excludes failures belonging to a separately named clinical condition or safety system, such as VTE prevention, pressure-ulcer care or NEWS-system operation, where that named concern provides the more specific supported boundary.
Excludes general personal care, hygiene, comfort or welfare omissions that do not involve physical nursing care or clinical treatment.
Excludes poor clinical or risk assessment where no deficiency in physical nursing care is identified.

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

Reports about this concern sent to each recipient.

Barts Health NHS Trust1

Calderdale and Huddersfield NHS Foundation Trust1

Department of Health and Social Care1

Enteral (GB) UK1

Hinchingbrooke Hospital1

International Organization for Standardization1

Medicines and Healthcare products Regulatory Agency1

NHS England1

Nursing Times1

Partnerships in Care Limited1

Pennine Care NHS Foundation Trust1

Royal College of Nursing1

Royal London Hospital1

Royal Stoke University Hospital1

South London and Maudsley NHS Foundation Trust1

Reports and published responses 12 reports

See individual reports that have raised this concern, and the actions taken in response

6 Mar2014
West Sussex
Concerns raised1
1. Sporadic and insufficient physical observations
This report raised 12 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 3
1. Partnerships in Care Group Limited
  Introduce enhanced physical-health monitoring, including daily morning observations for every patient by a trained nurse.
2. Partnerships in Care Group Limited
  Introduce a company-wide electronic dashboard to support completion of regular physical-health screening.
3. 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 2
1. 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.
  Disputes the concern
1. 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.
  Redirects responsibility
AI-generated summary

Natasha Raghoo · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Sporadic and insufficient physical observations
Wider context from the report
“2. Physical observations of blood pressure, pulse and temperature were sporadic and few in number. This was cause for concern as Natasha had a raised blood pressure and had been commenced on treatment, Observations stopped two days prior to death and no member of staff was able to explain who was responsible for this action. ”
Source location
Natasha Raghoo · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce enhanced physical-health monitoring, including daily morning observations for every patient by a trained nurse.

Verbatim wording from the response
“Lessons Learned and changes made”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 3 · response
Published 6 March 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Introduce a company-wide electronic dashboard to support completion of regular physical-health screening.

Verbatim wording from the response
“We have also introduced an electronic ‘dashboard’ across PiC. This tool provides staff with up to date information to ensure that regular physical health screening requirements are undertaken.”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 3 · response
Published 6 March 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.

Verbatim wording from the response
“Lessons Learned and changes made”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 6 · response
Published 6 March 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Blood-pressure observations were neither sporadic nor few, and the available evidence indicates they continued during the final two days.

Verbatim wording from the response
“Evidence was provided that the patient had 17 blood pressure readings taken over 5 consecutive days in the week prior to her death; we do not agree that this was sporadic or few in number, and as far as I’m aware, there has been no medical evidence criticising this.”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 2 · response
Published 6 March 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Any enhanced physical observations or ECG testing was expected to be ordered by the visiting GP or responsible Consultant Psychiatrist.

Verbatim wording from the response
“However, as you will appreciate, the Dene is a psychiatric unit and PiC complies with The Maudsley Guidelines for such matters as ECG usage. The Maudsley Guidelines in place at the time of the death (the 10th edition) do not recommend that routine ECGs be carried out for every patient. We would expect that if there were any enhanced needs for physical observations or tests of this sort, these would be ordered by either the visiting GP or the Consultant Psychiatrist responsible for the patient's care.”

Source location
2014-0100-Response-by-Partnership-in-Care
Page 3 · response
Published 6 March 2014
Open published response
13 Jan2014
Manchester South
Concerns raised1
1. 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 statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Barbara White · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to carry out required clinical and nursing observations
Wider context from the report
“1. There was a lack of clinical observations for a period of 12 hours on the 9th December. In addition no nursing observations were carried out during this period of time. ”
Source location
Barbara White · Prevention of Future Deaths report
Page 1 · concerns
Open source report