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
Individual concerns: 127
Date range: 2013–2026
Stated actions: 169

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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.

19 Sep2019
Manchester South
Concerns raised1
1. Failure to recognise early signs of sepsis and clinical deterioration in the NICU
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Caspian Thorn · 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

Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.

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 recognise early signs of sepsis and clinical deterioration in the NICU
Wider context from the report
“6. Early signs of sepsis were not identified by the consultant neonatologist because it was thought the observations reflected a move to warming from cooling. The other experienced staff within the NICU did not appear to recognise a deteriorating position until 12 hours after early signs of deterioration were noted. ”
Source location
Caspian Thorn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jun2019
West Sussex
Concerns raised1
1. Failure to consider NHS 111 advice for a deteriorating patient
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 1
1. Action
  Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
  Stated by Shaw Healthcare LimitedStated completed
AI-generated summary

James William Francis · 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

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

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 consider NHS 111 advice for a deteriorating patient
Wider context from the report
“I heard evidence that when Mr Francis was sick three times during the late afternoon and early evening of the day of his fall, no action was taken to seek out of hours medical advice In addition, despite a significant deterioration in Mr Francis condition later in the day of his fall and more significantly the following morning and after five separate referrals by the day support worker to the team leader, there was a five hour delay in making a simple telephone call to request a GP visit. Further, there does not appear to have been any thought given to making a call to NHS 111 for advice. It was also unclear exactly what information was given to the GP surgery to stress the history and deterioration in Mr Francis condition ”
Source location
James William Francis · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.

Verbatim wording from the response
“I also refer to the attached “Request for attendance of GP” policy which states that if a Service User develops a health problem or if the Service User requests to see their GP, the senior person on duty will assess the situation and contact the surgery, before the medication round commences. In assessing the urgency of the situation, the GP Surgery can be approached for advice or otherwise to liaise with the District Nursing service as appropriate it goes on to set very clear expectations in referring to the NHS 111 service and also the importance of clear communications.”

Source location
2019-0202-Response-by-Shaw-Healthcare
Page 3 · response
Published 23 August 2019
Open published response
24 Apr2019
Brighton and Hove
Concerns raised1
1. Failure to act on NEWS observations and escalate deteriorating patients
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Ioannis AVGOUSTI · 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

Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

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 act on NEWS observations and escalate deteriorating patients
Wider context from the report
“(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”
Source location
Ioannis AVGOUSTI · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.

Verbatim wording from the response
“Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call.”

Source location
2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Page 3 · response
Published 14 June 2019
Open published response
22 Jan2019
Birmingham and Solihull
Concerns raised1
1. Failure of junior staff to identify deterioration and escalate to senior staff
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
2. Action
  Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated completed
AI-generated summary

Ann Swoffer · 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

Ann Swoffer died on 02/09/18 after an oesophageal perforation developed following dilatation during naso-jejunal tube insertion. The report identified concerns about the procedure being contrary to accepted practice, delayed recognition and treatment of the perforation, inadequate escalation to senior staff at the weekend, and inconsistent practices and protocols across hospital sites.

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 of junior staff to identify deterioration and escalate to senior staff
Wider context from the report
“2. The deceased deteriorated as a result of a late perforation over the August Bank Holiday weekend. Junior staff did not identify the problem and did not escalate this to senior staff. I was told a “work force issue” meant senior staff were not present in the hospital at the time. Patients who become ill at the weekend need to receive the same standard of care as in the week. Consideration needs to be given to how this can be addressed. ”
Source location
Ann Swoffer · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.

Verbatim wording from the response
“At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.”

Source location
2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
Page 3 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.

Verbatim wording from the response
“At the time of Ms Swoffer’s admission, there was a consultant available on call at Good Hope Hospital and an upper gastrointestinal consultant surgeon on call and on site in Birmingham Heartlands Hospital. There was however no escalation to the consultants available over the weekend. We have worked with the clinical teams to ensure there is appropriate communication with senior medical staff regarding emergent complications regardless of time of day, or day of week. We have further increased routine on site attendance by a range of consultant staff over the weekend, to facilitate access to consultant opinions and help clarify lines of communication outside the times they are present. For example, at Good Hope Hospital there were no planned gastroenterology consultant ward rounds over the weekend at the time of the deceased’s admission.”

Source location
2019-0026-Response-by-University-Hospitals-Birmingham-NHS-Trust
Page 3 · response
Published 23 May 2019
Open published response
10 Jan2019
Manchester South
Concerns raised2
1. Failure to review patients and escalate care when EWS trigger points require it
2. Delayed doctor review during clinical deterioration
This report raised 11 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 4
1. Action
  Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Implemented NEWS2, including revised observation and escalation processes and associated staff training.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
3. Action
  Develop a triggered referral process to orthogeriatricians for patients requiring senior review.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
1. Action
  Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated planned
AI-generated summary

Michael William Flynn · 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

Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

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 review patients and escalate care when EWS trigger points require it
Wider context from the report
“2. The trust had a clear protocol regarding monitoring and trigger points for regularity and escalation in relation to EWS. Whilst Mr Flynn was a patient on the orthopaedic unit the Trust policy was not adhered to. For example the inquest heard that in the 18 hours preceding his death he did not see a doctor and was not reviewed despite the EWS scores requiring this to happen. ”
Source location
Michael William Flynn · Prevention of Future Deaths report
Page 2 · 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
Delayed doctor review during clinical deterioration
Wider context from the report
“4. He was only seen by a Doctor when a crash call went out and not in the period when there was a deteriorating clinical picture contrary to the Trust policy. ”
Source location
Michael William Flynn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.

Verbatim wording from the response
“The Matron for the Orthopaedic Unit has provided assurances that formal discussions have taken place with the nursing staff identified through our investigation as failing to comply with Trust Policy in respect to the regularity, recording and appropriate escalation of NEWS observations, and consideration given to identified support or training needs. Additionally, I understand the ward manager has circulated a newsletter to all staff reiterating their responsibilities and accountability with regards to the appropriate recording and escalation of NEWS, including -”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 2 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implemented NEWS2, including revised observation and escalation processes and associated staff training.

Verbatim wording from the response
“Although not directly relevant in the context of this Regulation 28 Report, I would like to advise you of a change made within the Trust relating to the National Early Warning Score (NEWS). At the time of Mr. Flynn’s episode of care, the Trust were using a modified/adapted NEWS tool, which had been in use since 2014. In 2018, a Patient Safety Alert was published requiring Trusts to adopt a revised National Early Warning Score (NEWS2) drafted by the Royal College of Physicians. The alert resulted from the recognition that healthcare providers used a variety of adapted NEWS or locally devised early warning scores, increasing the risk of harm resulting from having different scoring systems in use across the NHS when patients or staff move between services.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 3 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a triggered referral process to orthogeriatricians for patients requiring senior review.

Verbatim wording from the response
“In addition, I am informed that discussions have taken place with the Directorate of Medicine to implement a triggered referral process to the Orthogeriatricians in cases where patients are identified as requiring a senior level orthogeriatric review. I have gained assurances from the Deputy Directorate Manager for Trauma and Orthopaedics that she is currently working with the Directorate Manager for Medicine to develop the process. The Specialty anticipates that these measures will provide additional support to the clinical teams and patients, ensuring senior medical reviews take place appropriately.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 4 · response
Published 23 May 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.

Verbatim wording from the response
“To obtain some assurance in this matter, I understand a review of case notes is scheduled to commence in March 2019 on both the Planned and Emergency Orthopaedic wards to evaluate the medical documentation in relation to daily entries in the medical notes, the grade of doctor reviewing the patient, and whether an orthogeriatric review has taken place where indicated.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 4 · response
Published 23 May 2019
Open published response
21 Dec2018
Norfolk
Concerns raised1
1. Failure to recognise worsening condition from blood results
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 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.
AI-generated summary

William Clifford ATHERTON · 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

William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

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 recognise worsening condition from blood results
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Nov2018
South Yorkshire (Eastern)
Concerns raised1
1. Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients
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.
AI-generated summary

Roy Burgess · 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

Roy Burgess, aged 87, was admitted after a fall at home that caused a left femoral fracture and was transferred for surgery. The report identified missed opportunities to recognise and escalate his deteriorating condition, inadequate clinical record-keeping, and untimed ward-round notes entered non-chronologically. The inquest concluded that it was unlikely that intervention would have altered the outcome.

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 adhere to the Early Warning System for identifying and escalating deteriorating patients
Wider context from the report
“(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management. ”
Source location
Roy Burgess · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Oct2018
Liverpool and the Wirral
Concerns raised3
1. Failure to escalate and convey the severity of deterioration to the Critical Care Team
2. Failure to review an initial diagnosis when the patient deteriorates
3. Delays in administering antibiotic therapy during clinical deterioration
This report raised 9 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.
AI-generated summary

Tom Cribley · 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

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

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 escalate and convey the severity of deterioration to the Critical Care Team
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · 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 review an initial diagnosis when the patient deteriorates
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · 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
Delays in administering antibiotic therapy during clinical deterioration
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
11 Jul2018
Brighton and Hove
Concerns raised1
1. Failure to recognise the urgency of treatment for septic patients
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 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.
AI-generated summary

Rita Elizabeth GILES · 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

Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.

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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 the urgency of treatment for septic patients
Wider context from the report
“(1) Unnecessary transfers to and from the Princess Royal Hospital with no supporting paperwork. (2) The Trust’s own Transfer Policy not adhered too in any respect. (3) Delay in her endoscopic retrograde cholangiopancreatography ERCP until she was so ill that it needed to be done on the CEPOD list under general anaesthetic and required ICU support. This lady never recovered from this procedure and died a few days later. (4) At Inquest it was explained to me that there are only three people in the Trust that can carry out ERCP work, they have one list each a week, lists are only on Mondays, Wednesdays and Fridays. The lists seem to be booked well in advance so there is little or no resource for the patient who comes in as Miss Giles did with an urgent requirement. There was a failure to appreciate that as she was already septic when she came in the matter was urgent. From the Inquest it appeared that the Princess Royal Hospital was not the right place for her to be, there is argument to suggest that she should have been transferred early to the Royal Sussex County Hospital in Brighton and presumably if she needed urgent treatment she could have had it. Surely, the lists are designed to accommodate the patients not the other way round. ”
Source location
Rita Elizabeth GILES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jul2018
Wiltshire and Swindon
Concerns raised1
1. Inadequate algorithm for assessing deterioration risk in intoxicated people
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eugeniusz Niedziolko · 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

Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.

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
Inadequate algorithm for assessing deterioration risk in intoxicated people
Wider context from the report
“g) 2017 AGREEMENT – I raised with Consultant Paramedic ████████, and he is aware of my concern, that given the evidence of ████████ Consultant in Accident & Emergency who gave evidence that even if the observations had been carried out which to the greatest sense and purpose includes the checks in algorithm on page 10 of 12 of the 2017 Agreement, I am not convinced that if another Eugeniusz was to crop up that this risk of significant deterioration and death would have been picked up and avoided using this algorithm. Sometimes you have to spell it out and there was no questioning in this case as to when the person last consumed alcohol and over what period and what quantity they had consumed relative to this decision-making process. I queried whether especially with somebody who is not being cooperative as to whether the use of a breathalyser (if they were to consent) would aid in the intelligence gathering. There is also no mention of physical presentation. In Eugeniusz’s case, he had become incontinent of urine in respect of which I asked all relevant witnesses as to how many people they knew who were deliberately incontinent of urine. The answer, not unsurprisingly, was no-one. That factor from the common-sense point of view either is suggestive of physical issue whereby Eugeniusz was incontinent or that it was related to the degree of his intoxication in that he could no longer control and had no awareness of bodily function in that respect. The algorithm needs to be reviewed and considered in the light of this case specifically so that it would pick up another “Eugeniusz”. ”
Source location
Eugeniusz Niedziolko · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to recognise early signs of sepsis and clinical deterioration in the NICU

Concerns raised1

Failure to consider NHS 111 advice for a deteriorating patient

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

Concerns raised1

Failure to act on NEWS observations and escalate deteriorating patients

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

Concerns raised1

Failure of junior staff to identify deterioration and escalate to senior staff

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

Concerns raised2

Failure to review patients and escalate care when EWS trigger points require it

Delayed doctor review during clinical deterioration

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

Concerns raised1

Failure to recognise worsening condition from blood results

Concerns raised1

Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients

Concerns raised3

Failure to escalate and convey the severity of deterioration to the Critical Care Team

Failure to review an initial diagnosis when the patient deteriorates

Delays in administering antibiotic therapy during clinical deterioration

Concerns raised1

Failure to recognise the urgency of treatment for septic patients

Concerns raised1

Inadequate algorithm for assessing deterioration risk in intoxicated people

Actions described in response 1

Actions described in response 1

Actions described in response 2

Actions described in response 4