Recurring concern

Failure to reliably recognise and respond to acute clinical deterioration

Get email alerts

Request correction

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.

18 May2017
London (West)
Concerns raised1
1. Lack of regular monitoring and documentation of physical vital signs in acute mental health settings
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 1
1. Action
  Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.
  Stated by NHS EnglandStated in progress
AI-generated summary

Alice Amaryllis Gibson-Watt (“Alice”) · 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

Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

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
Lack of regular monitoring and documentation of physical vital signs in acute mental health settings
Wider context from the report
“This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. I am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. I am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have seen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ”
Source location
Alice Amaryllis Gibson-Watt (“Alice”) · 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
Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.

Verbatim wording from the response
“• In parallel, NHS England continues to support the ongoing inspection and regulation of mental health in-patient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS.”

Source location
2017-0163-Response-by-NHS-England
Page 2 · response
Published 17 August 2017
Open published response
20 Apr2017
South Wales Central
Concerns raised2
1. Failure to appropriately escalate care in response to deteriorating NEWS scores
2. Delays in clinical review of patients with deteriorating NEWS scores
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.
AI-generated summary

Harold Mullins · 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

Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

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 appropriately escalate care in response to deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Source location
Harold Mullins · 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
Delays in clinical review of patients with deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Source location
Harold Mullins · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Mar2017
Norfolk
Concerns raised1
1. Delays and failures in escalating serious patient deterioration to senior medical staff
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.
AI-generated summary

James Charles MALLETT · 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 Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.

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 and failures in escalating serious patient deterioration to senior medical staff
Wider context from the report
“(2) There was no apparent urgency to secure the prompt attendance of a doctor to assess the patient. The nursing staff, who were described by Sr Snowden as a "junior workforce" did not seem to understand the seriousness of the injury and did not seek senior help from the night team. The nursing staff did not carry out regular and/or timely neurological observations. ”
Source location
James Charles MALLETT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Mar2017
Manchester City
Concerns raised1
1. Failure by doctors and nurses to escalate patient deterioration
This report raised 14 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

Mrs Kathleen Cooper · 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

Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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 by doctors and nurses to escalate patient deterioration
Wider context from the report
“3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”
Source location
Mrs Kathleen Cooper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Oct2016
Brighton and Hove
Concerns raised1
1. Failure to assess and investigate reported respiratory deterioration
This report raised 17 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

Leslie Isaac LERNER · 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

Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

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 assess and investigate reported respiratory deterioration
Wider context from the report
“17th May – 22nd May 2016 There is no evidence of any continuity of care. There is good evidence of “hands off” care and nursing. In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering. No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics. In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing. ”
Source location
Leslie Isaac LERNER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Oct2016
South Yorkshire (Western)
Concerns raised1
1. Delays and lack of clarity in prescribing deterioration monitoring
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 2
1. Action
  Introduce an Acute Response Team of Advanced Nurse Practitioners to rapidly support wards when patients deteriorate.
  Stated by Barnsley Hospital NHS Foundation TrustStated completed
2. Action
  Invest in the VitalPac electronic observation system to improve recognition and response for deteriorating patients.
  Stated by Barnsley Hospital NHS Foundation TrustStated completed
AI-generated summary

Captain James Michael Bedford · 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

Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

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 and lack of clarity in prescribing deterioration monitoring
Wider context from the report
“3. Whilst it is accepted that Emergency Departments are often busy, and sometimes exceptionally so, there was criticism at the inquest of the priority given to Captain Bedforth on his second admission when he was displaying classical symptoms of a DVT/PE. It appears that he was not medically assessed for at least two and a half hours after admission by ambulance. Deterioration was not prescribed until three hours post-admission and there was no evidence as to exactly when it was given (although likely shortly thereafter). ”
Source location
Captain James Michael Bedford · 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
Introduce an Acute Response Team of Advanced Nurse Practitioners to rapidly support wards when patients deteriorate.

Verbatim wording from the response
“4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.”

Source location
2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016
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
Invest in the VitalPac electronic observation system to improve recognition and response for deteriorating patients.

Verbatim wording from the response
“4. We have and continue to ensure there are sound processes in all clinical areas regarding prompt escalation of unwell patients. This is covered on the induction programme for all medical students who are very familiar with the need to escalate if they see someone who is acutely unwell. We have also recently introduced an Acute Response Team of Advanced Nurse Practitioners who rapidly attend to support wards with patients who deteriorate. We have also invested in the VitalPac electronic observation system that has been demonstrated in other Trusts to improve the recognition and response for sick patients.”

Source location
2016-0368-Barnsley-Hospital-NHS-Trust
Page 2 · response
Published 18 October 2016
Open published response
18 Aug2016
Brighton and Hove
Concerns raised1
1. Failure to increase observation frequency during clinical 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.
AI-generated summary

Diana Maxine RITCHIE · 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

Diana Maxine Ritchie was recovering from major surgery when she deteriorated overnight on 5–6 March and suffered a cardiac arrest at around 12.20 hrs on 6 March. Concerns included missed opportunities to escalate care in response to raised NEWS scores, inaccurate or potentially delayed observations, and failures in the use of NEWS across the Trust.

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 increase observation frequency during clinical deterioration
Wider context from the report
“(4) The other area of concern I have is that the observations were not taken more regularly during the night of the 5th/6th March when it was clear that Mrs Ritchie's condition was deteriorating – it should not have needed any form of direction from the doctors attending for these observations to be taken more regularly. The Nurse in charge of the ward should have been informed and should have made a direction for the appropriate timing of these observations. ”
Source location
Diana Maxine RITCHIE · Prevention of Future Deaths report
Page 1 · concerns
Open source report
12 Aug2016
West Sussex
Concerns raised1
1. Failure to review patients after acute NEWS score 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 5
1. Action
  Adopt SBAR documentation and a dedicated form for recording critical telephone conversations in patient health records.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Provide a 24-hour Critical Care Outreach Team service at Princess Royal Hospital to support deteriorating patients.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
1. Action
  Remind Twineham ward nursing staff to escalate patient concerns to the nurse in charge.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Roster a trained senior Band 6 nurse on Twineham ward throughout the 24-hour period to provide guidance and support escalation.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
AI-generated summary

Jean Stockley · 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

Jean Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.

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 after acute NEWS score deterioration
Wider context from the report
“1. On 9 April, Mrs Stockley's respiratory condition was clearly deteriorating necessitating critical care review who recommended careful and consistent observation of principally her oxygen saturation levels. The NEWS score was a vital tool to alert clinical staff to an acute change yet despite the fact the score went from 4 to 8, the junior doctor did not review the patient. I heard evidence from nursing staff that the doctor felt the patient may simply have been anxious. This suggests a potential training need for doctors and/or nurses. ”
Source location
Jean Stockley · 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
Adopt SBAR documentation and a dedicated form for recording critical telephone conversations in patient health records.

Verbatim wording from the response
“1. I regret that the documentation arising from the nurse’s call to the doctor after the NEWS score had risen was so brief, and that neither the doctor nor the nurse concerned could recall this telephone conversation at all. The ward has since adopted a protocol known as SBAR (Situation / Background/Assessment/Recommendation), which includes documentation. This helps staff (especially nurses) to frame critical conversations raising concern about their patient, and has been shown to improve communication and patient safety. A special form is used to prepare for and record such telephone conversations, and is then placed in the patient’s health records as a record of the call. I was disappointed to learn that on this occasion the doctor had apparently not visited the ward when he was notified of the sudden rise in Mrs Stockley’s NEWS score.”

Source location
2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 12 August 2016
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
Provide a 24-hour Critical Care Outreach Team service at Princess Royal Hospital to support deteriorating patients.

Verbatim wording from the response
“2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

Source location
2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 12 August 2016
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
Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.

Verbatim wording from the response
“2. Since April 2015, there have been several changes at the Princess Royal Hospital. The Critical Care Outreach Team, to whom you refer, implemented a 24 hour service on the site from June 2015, so are readily available to support and advise on the care of any patient whose condition is deteriorating. A revised NEWS policy has been introduced but it is recognised that some flexibility is required to ensure that contact is made with the member of staff who is most likely to be able to offer timely assistance to the patient. At night, there is no orthopaedic registrar present on the Princess Royal Hospital site, and the critical care and medical registrars who are on site are often better placed to assess the immediate needs of a patient whose condition has unexpectedly changed.”

Source location
2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 12 August 2016
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
Remind Twineham ward nursing staff to escalate patient concerns to the nurse in charge.

Verbatim wording from the response
“3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

Source location
2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 12 August 2016
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
Roster a trained senior Band 6 nurse on Twineham ward throughout the 24-hour period to provide guidance and support escalation.

Verbatim wording from the response
“3. Nursing staff on Twineham ward have been reminded that rather than simply handing over to the nurse who will be taking over direct care of a patient on the next shift, any concern about a patient should be drawn to the attention of the nurse in charge. Since June 2016, a senior nurse (band 6) has been rostered to be on duty on the ward throughout the 24 hour period. This person is trained to provide advice, support and clinical guidance to other nurses, including ensuring that appropriate assistance is obtained in the event of a patient deteriorating. It is also the responsibility of the Band 6 nurse to contact a more senior member of the medical team if there is cause for concern arising from advice received from the junior doctor first contacted.”

Source location
2016-0286-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 12 August 2016
Open published response
30 Jun2016
Manchester North
Concerns raised1
1. Failure to recognise signs and symptoms of neonatal 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 2
1. Action
  Provide mandatory Care of the Compromised Infant training to midwives to support early detection and appropriate response to deterioration.
  Stated by The TrustStated completed
2. Action
  Introduce a newborn observation chart based on the British Association of Paediatric Medicine Newborn Early Warning Score.
  Stated by The TrustStated in progress
AI-generated summary

baby Dominic Smith · 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

Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.

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 signs and symptoms of neonatal deterioration
Wider context from the report
“Pennine Acute Hospitals NHS Trust: 1. During the course of the inquest into Baby Smith’s death, the following concerns arose: - Inadequate communication, handover and record keeping; - Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion; - Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this; - Early warning scores were i) miscalculated, ii) not acted upon; - Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed; - Maternal observations were not carried out after delivery, despite a spike in temperature; - Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist & - Inadequate preceptorship for newly qualified (and particularly part-time) Midwives. ”
Source location
baby Dominic Smith · 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
Provide mandatory Care of the Compromised Infant training to midwives to support early detection and appropriate response to deterioration.

Verbatim wording from the response
“The neonatal services has developed a module of training entitled Care of the Compromised Infant, which now forms part of each midwife’s mandatory training; the”

Source location
2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
Page 2 · response
Published 30 June 2016
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
Introduce a newborn observation chart based on the British Association of Paediatric Medicine Newborn Early Warning Score.

Verbatim wording from the response
“There has been an audit as part of the divisional yearly programme looking at compliance with the Early Onset Sepsis Guidelines. Actions put in place following the audit was to introduce a new observation chart based on the Newborn Early Warning Score recommended by British Association of Paediatric Medicine (BAPM) and this work is in progress. Once completed there will be further audits to monitor compliance.”

Source location
2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
Page 3 · response
Published 30 June 2016
Open published response
25 Apr2016
Manchester City
Concerns raised1
1. Failure to recognise and act on symptoms of possible anaphylactic shock
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.

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

Norma Edwina Holden · 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

Norma Edwina Holden presented to the Accident and Emergency Department with abdominal pain, facial and mouth swelling, a swollen tongue and muffled speech, and was later found to have died from septic shock. Concerns included incomplete history-taking and communication to treating doctors, failure to recognise and act on apparent symptoms such as possible anaphylactic shock, lack of appropriate tests, and failure to obtain basic blood tests for infection or 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 and act on symptoms of possible anaphylactic shock
Wider context from the report
“During the inquest evidence was heard to the fact that Mrs Holden presented to the Accident and Emergency Department with a history of abdominal pain. Triage history stated swelling to face and mouth. It appears that Mrs Holden had a swollen tongue and her speech was muffled. ████████ was unaware of the symptoms of swollen tongue and facial swelling. I am concerned that the history taking is incomplete and not reported to treating doctors appropriately and that obvious symptoms appear to have not been noticed and actioned, such as possible anaphylactic shock, and appropriate tests conducted. In addition, basic blood tests were not obtained for analysis of any infection/sepsis, to enable appropriate targeting of antibiotics. ”
Source location
Norma Edwina Holden · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of regular monitoring and documentation of physical vital signs in acute mental health settings

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 raised2

Failure to appropriately escalate care in response to deteriorating NEWS scores

Delays in clinical review of patients with deteriorating NEWS scores

Concerns raised1

Delays and failures in escalating serious patient deterioration to senior medical staff

Concerns raised1

Failure by doctors and nurses to escalate patient deterioration

Concerns raised1

Failure to assess and investigate reported respiratory deterioration

Concerns raised1

Delays and lack of clarity in prescribing deterioration monitoring

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 raised1

Failure to increase observation frequency during clinical deterioration

Concerns raised1

Failure to review patients after acute NEWS score 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.5

Concerns raised1

Failure to recognise signs and symptoms of neonatal 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.2

Concerns raised1

Failure to recognise and act on symptoms of possible anaphylactic shock

Actions described in response 1

Actions described in response 2

Actions described in response 5

Actions described in response 2