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
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
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.
Essex
Concerns raised2
Failure to recognise deteriorating clinical condition
Failure to recognise changing oxygen requirements and heart rate as signs of deterioration
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.
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.3
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.
Position
The clinical presentation did not clearly indicate impending acute deterioration from upper gastrointestinal obstruction or grossly abnormal electrolytes.
Stated by East Suffolk and North Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Insufficient training of community and primary care teams to recognise deterioration in healing fractures
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations
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 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.
Derby and Derbyshire
Concerns raised1
Failure to recognise the significance of the first four hours after birth when assessing possible neonatal deterioration
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 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
Implement the NEWTT2 framework for newborn assessment, escalation and review.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Amend and implement NEWTT2 guidance to standardise escalation for neonatal respiratory distress.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Essex
Concerns raised1
Delays in medical review of acute clinical deterioration
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 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
Use Nervcentre task lists to communicate outstanding patient tasks between day and night teams during clinical handover.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Action
Provide out-of-hours patient-care coordination through a dedicated Hospital at Night team.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Bedfordshire and Luton
Concerns raised1
Failure to review incident management in response to evidence of deterioration during a 999 call
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 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
Integrate the Critical Care desk function into all three control rooms to improve identification, monitoring and reassessment of enhanced-care needs.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Publish an article in the weekly AOC staff newsletter reminding staff to actively listen and escalate calls where appropriate.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Address active listening and appropriate call escalation specifically with call handlers during supervision or one-to-one meetings.
Stated by East of England Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Nottinghamshire
Concerns raised2
Failure to recognise deteriorating patients
Delays in escalating deteriorating patients for acute secondary care intervention
This report raised 10 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.6
Action
Scope physical healthcare models across inpatient services and roll the work out across all services.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Deliver NEWS2 training to all frontline clinical staff required to undertake the assessment.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Provide clinical supervision through senior Quality Matrons to support NEWS2 practice and continuous learning.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Introduce scenario-based NEWS2 examples during clinical supervision to assess staff competency around escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Undertake a further training needs analysis to identify enhancements to frontline knowledge and clinical skills.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Review and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
West Yorkshire Eastern
Concerns raised1
Failure to escalate, assess and investigate NEWS-triggered deterioration
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 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
Maintain and improve escalation protocols for recognising and responding to deteriorating patients.
Stated by Mid Yorkshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Provide ongoing deterioration-response education to nursing, allied health and junior medical staff.
Stated by Mid Yorkshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Provide a 24/7 Deteriorating Adult Response Team for patients meeting deterioration referral criteria.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Augment the deteriorating-patient response service with additional capacity.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Operate the Call 4 Concern patient-safety initiative, connecting ward calls from patients or families to Deteriorating Adult Response Team members.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Points 1 and 4 of the concerns are not directly relevant to the RCR’s remit or responsibilities.
Stated by Royal College of RadiologistsOutside remitThe respondent said that this matter was outside its role or authority.
Inner North London
Concerns raised2
Failure to escalate care in response to clearly expressed parental concerns about a deteriorating child
Failure to recognise the severity of a seriously ill child’s condition
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
Develop, ratify, disseminate and audit a paediatric examination SOP covering escalation, SBAR handovers, senior opinions and mandatory face-to-face review before discharge.
Stated by London North West University Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2023.
Action
Advise clinicians to seek senior review when caregivers remain concerned after clinical review.
Stated by London North West University Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
Action
Implement the nationally approved Paediatric Early Warning System observation and escalation charts.
Stated by London North West University Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2023.
Action
Operate point-of-care testing for Streptococcus A and respiratory illness within the emergency pathway.
Stated by London North West University Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
Action
Add paediatric cases and learning from pertinent clinical presentations as a standard agenda item for the monthly Deteriorating Patients Group.
Stated by London North West University Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2023.
Surrey
Concerns raised1
Failure to recognise cardiac arrest
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 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 sourced vital-signs training information to current clinical staff and new clinical starters.
Stated by Leonard Cheshire DisabilityStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
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Includes failures to recognise, monitor, escalate, obtain clinical review for or respond to acute physical deterioration when the deterioration hazard itself is directly asserted.
