Recurring concern

Failure to reliably recognise and respond to acute clinical deterioration

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First reported 24 Sep 2013•Latest report 24 Jun 2026

Definition

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

Distinct published reports

Individual concerns
127

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
169

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 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

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.

  1. Manchester South

    AI-generated summary

    Frederick William Hall · 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

    Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.

    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

    Delays in seeking clinical review of deteriorating patients

    Wider context from the report

    “3. The monitoring of, and response to, the patient's condition seemed somewhat erratic. Both the surgeon and the senior nurse agreed that "an earlier review" should have been sought and that observations should have been taken more promptly following the patient having chest pains. ”

    Source location

    Frederick William Hall · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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 provide ongoing surgical assessment and response to deterioration

    Wider context from the report

    “(1) Delay in being seen both by Nursing Staff and Doctors in A & E. Delay in being seen by Surgical Team after referral to them at 05:30 hours on the 13th July 2013. Delay in ongoing assessment by the Surgical Team when he started to deteriorate and no Surgical Team member was available to respond to the calls for help from the Nursing Staff at the Acute Medical Unit. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 recognise patient deterioration

    Wider context from the report

    “(4) There was a failure to appreciate his deterioration largely because he was not seen by the Surgical Team in spite of requests that he should be seen. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. South Yorkshire (Western)

    AI-generated summary

    Jude Augustus Gordon · 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

    Jude Augustus Gordon underwent surgery and anaesthesia on 23 November 2011, deteriorated with signs of respiratory failure on 27 November, and died shortly after suffering a cardiac arrest. The concerns included failure to escalate his treatment or refer him to critical care, miscalculation of the Early Warning Score, variation in how scores were calculated between Trusts, and the absence of an automatic alert system for senior clinicians.

    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 contact a consultant when Early Warning Scores indicate clinical deterioration

    Wider context from the report

    “(2) Evidence was given at the inquest, by a consultant, that if he had been called to see Mr Gordon at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened, then he would have referred to critical care. He was not contacted. I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for contact to be required. Such a system would on the 27th November 2011, to the consultant attending on Mr Gordon. ”

    Source location

    Jude Augustus Gordon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026