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.
Milton Keynes
Concerns raised1
Failure to closely monitor deteriorating patients after PEG insertion
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 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.
Nottinghamshire
Concerns raised1
Delays in obtaining and utilising physical monitoring equipment for patients with concerns for their breathing
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Failure of senior healthcare leadership oversight of care planning and deterioration
This report raised 7 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 dedicated Resus Lead support, onsite training, scenario coaching, code-call shadowing and feedback for deteriorating-patient care.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Inner North London
Concerns raised1
Failure to recognise deterioration and commence CPR promptly
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 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
Require all officers to complete digital training on recognising agonal breathing to support earlier CPR.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Standardise jaw-thrust airway management, retain casualties on their backs, limit recovery-position use to clearing fluids, and commence CPR when noisy breathing persists.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 10 July 2023.
Action
Deliver expanded Emergency Life Support Module 2 and refresher training, including additional practical scenario-based drills and techniques.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 July 2023.
West Yorkshire Eastern
Concerns raised2
Failure by the reviewing doctor to escalate patient deterioration
Failure to alert senior clinicians to unexpected patient deterioration
This report raised 13 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
Provide NEWS refresher training to relevant colleagues and conduct regular audits of NEWS compliance.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Deliver training to RMOs on recognising deteriorating patients and signs of gastric perforation.
Stated by Spire Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Introduce deteriorating-patient stickers for clinical use.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Referral of the RMO to the GMC was considered unnecessary because the RCA findings and known practice did not meet the referral threshold.
Stated by Spire Healthcare LimitedNo action considered necessaryThe respondent said that no further action was needed.
Position
The RMO’s agency was considered best placed to assess whether the incident was isolated or required wider performance action or GMC escalation.
Stated by Spire Healthcare LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Failure to recognise deterioration in a patient's presentation promptly
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
Implement early-morning bedside review of AMU patients to identify deterioration and refer patients to appropriate clinical teams.
Stated by Royal Cornwall HospitalStated plannedThe respondent said that this action was planned when they made their response on 30 January 2023.
Milton Keynes
Concerns raised1
Failure to upgrade emergency incident categorisation when clinical deterioration warranted a higher priority
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 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.
Milton Keynes
Concerns raised2
Failure to provide effective senior review of deteriorating patients
Failure to effectively and consistently monitor patients for 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to respond to concerning clinical states with necessary urgency
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Worcestershire
Concerns raised1
Delays in calling an ambulance when a resident’s condition requires emergency assistance
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
