Recurring concern
Failure to reliably recognise and respond to acute clinical deterioration
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Request correctionFirst reported 24 Sep 2013•Latest report 24 Jun 2026
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.
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.
- Reports
- 103
- Individual concerns
- 127
- Date range
- 2013–2026
- Stated actions
- 169
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of on-call consultants to obtain or receive updated information about patient deterioration
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to recognise deterioration in respiratory condition
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to complete National Early Warning System scoring after acute deterioration
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 concernsEach 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.2
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Position
NEWS scores were not expected during the medical emergency because the early warning system had already fulfilled its function.
Stated by University Hospitals Sussex NHS Foundation Trust
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Position
No remedial action was considered necessary because the medical records contained appropriate detail about AMU care and NEWS scores.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to reassess diagnoses and escalate treatment despite continuing clinical decline
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 concernsEach 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
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Action
Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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Concerns raised1
Failure to monitor and respond promptly to postoperative neck and facial swelling
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to obtain appropriate senior medical review or support when deterioration is identified
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide close monitoring of patients at high risk of acute deterioration
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 concernsEach 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
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Action
Implement revised NEWS and CREWS early warning scores across Newham University Hospital and the Trust.
Stated by Barts Health NHS Trust -
Action
Pilot Vitalslink wireless vital-sign monitoring with real-time alerts linked to the electronic patient record.
Stated by Barts Health NHS Trust -
Action
Improve participation by all on-call teams in refreshed hospital-at-night meetings to review patients flagged as at risk.
Stated by Barts Health NHS Trust
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Action
Train nursing staff in recognising deteriorating patients and appropriately escalating concerns.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to escalate changes in patient condition for timely medical assessment
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in recognising deteriorating condition
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to escalate care after deteriorating neurological 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026