Failure to reliably recognise and respond to acute clinical deterioration
First to latest report 24 Sep 2013 — 24 Jun 2026
Reports that mention this concern
103
Times this concern has been raised
127
Stated actions linked to this concern
169
What this concern includes
Includes failures to recognise, monitor, escalate, obtain clinical review for or respond to acute physical deterioration when the deterioration hazard itself is directly asserted.
What is not included
Excludes generic communication, staffing, training or senior-oversight failures not directly tied to an identified deterioration episode or control.
Excludes deterioration in mental health, and condition-specific systems that do not establish a wider acute-deterioration failure.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care14
NHS England10
Care Quality Commission6
University Hospitals Sussex NHS Foundation Trust6
National Institute for Health and Care Excellence4
Nottinghamshire Healthcare NHS Foundation Trust4
Recipient name withheld3
Royal Sussex County Hospital3
Barts Health NHS Trust2
College of Policing2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2
Lewisham and Greenwich NHS Trust2
Manchester University NHS Foundation Trust2
Medway NHS Foundation Trust2
Metropolitan Police Service2
NHS trust53
Healthcare site17
Ministerial department15
Executive non-departmental public body14
Private limited company7
Health and social care service regulator6
Nursing home6
Type not available5
Health professional body4
Integrated care board4
Multi-service care provider3
Police force3
Residential care home3
Devolved government2
English county council2
Reports and published responses 103 reports
See individual reports that have raised this concern, and the actions taken in response
Worcestershire
Concerns raised1
Failure to carry out checks or observations on a deteriorating patient
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Worcestershire Acute Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Worcestershire Acute Hospitals NHS Trust
Complete the commissioned case review to identify system improvements and examine its findings for wider learning.
Worcestershire Acute Hospitals NHS Trust
Update the discharge lounge SOP on patient capacity, deteriorating-patient management, and exclusion criteria for unsuitable patients.
Worcestershire Acute Hospitals NHS Trust
Require the discharge lounge team to record full observations electronically and use SBAR escalation for deterioration or medical emergencies.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Worcestershire Acute Hospitals NHS Trust
The patient was in the discharge lounge before transfer, not the PDU.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Failure to recontact the EMA when a caller reports deterioration
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Appello Careline Limited
Association of Ambulance Chief Executives
NHS England
TSA
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
TSA
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Appello Careline Limited
The failure to communicate deterioration was an individual failure to follow established procedures, not a deficiency in those procedures.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Appello Careline Limited
Further procedural change is not considered necessary because established training, audit and supervision processes will continue reinforcing compliance.
No action considered necessaryThe respondent said that no further action was needed.
Appello Careline Limited
Existing procedures, training, auditing and continuous improvement provide a robust framework for managing the identified risks.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Association of Ambulance Chief Executives
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of District Nurses to promptly escalate deteriorating patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Tameside and Glossop Integrated Care NHS Foundation Trust
Introduce Team Leader of the Day and Coordinator of the Day roles to provide senior support and clear escalation routes.
Tameside and Glossop Integrated Care NHS Foundation Trust
Use daily SITREP and out-of-hours handover processes to monitor capacity, demand and acuity and escalate urgent staffing pressures.
Tameside and Glossop Integrated Care NHS Foundation Trust
Increase caseload reviews and triage to prioritise patients with complex, frail, end-of-life or changing clinical needs.
Tameside and Glossop Integrated Care NHS Foundation Trust
Conduct deteriorating-patient audits and systematically monitor pathway use, clinical observations and NEWS2 compliance across teams.
Tameside and Glossop Integrated Care NHS Foundation Trust
Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
Bedfordshire and Luton
Concerns raised1
Failure to recognise and escalate clinical deterioration
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
HM Prison and Probation Service
Northamptonshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Northamptonshire Healthcare NHS Foundation Trust
Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.
Northamptonshire Healthcare NHS Foundation Trust
Facilitate mandatory induction training for healthcare staff on detecting and managing suspected illicit-substance influence.
HM Prison and Probation Service
Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
HM Prison and Probation Service
Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
HM Prison and Probation Service
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
Essex
Concerns raised1
Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
the Princess Alexandra Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
the Princess Alexandra Hospital NHS Trust
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Newcastle and North Tyneside
Concerns raised1
Failure to recognise the greater role of heart failure in deterioration
This report raised 2 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.
Liverpool and the Wirral
Concerns raised1
Failure to obtain timely alternative clinical input when the registered GP is unavailable
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Riversdale (Northwest) Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Riversdale (Northwest) Limited
Supervise senior care assistants on obtaining clinical support, including contacting 111 or 999 when residents are unwell and a GP is unavailable.
Riversdale (Northwest) Limited
Arrange local GP registration within 24 hours for new out-of-district residents and obtain 111 advice if they become unwell before registration.
South Wales Central
Concerns raised5
Delays in recognising acute deterioration in people with learning disabilities
Delays in responding to acute deterioration in people with learning disabilities
Delays in escalating acute deterioration in people with learning disabilities
Lack of familiarity with the use of an acute deterioration recognition tool in Wales
Lack of a specific practice tool for recognising, escalating and responding to potential acute deterioration in people with learning disabilities
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cabinet Secretary for Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Cabinet Secretary for Health and Social Care
Incorporate annual learning disability health checks into the GP Wales core contract for eligible adult patients.
Cabinet Secretary for Health and Social Care
Provide additional funding to health boards to embed annual learning disability health checks and support GP practices.
Cabinet Secretary for Health and Social Care
Support enhancements with NHS Performance and Improvement to ensure high-quality annual learning disability health checks.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Cabinet Secretary for Health and Social Care
Local authorities or commissioning bodies are responsible for ensuring care workers receive relevant training through individual care plans.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure to escalate deteriorating patients for medical assessment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Strengthen verbal handovers during shift changes to support identification and escalation of safety concerns.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Launch and embed Trust-wide Safety Huddles at BDGH for real-time identification and escalation of safety concerns.
Worcestershire
Concerns raised1
Failure to recognise post-fall deterioration and seek timely medical assessment
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Green Range Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Green Range Limited
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Green Range Limited
Provided fall prevention and management training to staff.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.