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.
Worcestershire
Concerns raised1
Failure to carry out checks or observations on a deteriorating patient
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
Complete the commissioned case review to identify system improvements and examine its findings for wider learning.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2026.
Action
Update the discharge lounge SOP on patient capacity, deteriorating-patient management, and exclusion criteria for unsuitable patients.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 September 2026.
Action
Require the discharge lounge team to record full observations electronically and use SBAR escalation for deterioration or medical emergencies.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The patient was in the discharge lounge before transfer, not the PDU.
Stated by Worcestershire Acute Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Failure to recontact the EMA when a caller reports deterioration
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
Stated by TSAStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The failure to communicate deterioration was an individual failure to follow established procedures, not a deficiency in those procedures.
Stated by Appello Careline LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Further procedural change is not considered necessary because established training, audit and supervision processes will continue reinforcing compliance.
Stated by Appello Careline LimitedNo action considered necessaryThe respondent said that no further action was needed.
Position
Existing procedures, training, auditing and continuous improvement provide a robust framework for managing the identified risks.
Stated by Appello Careline LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of District Nurses to promptly escalate deteriorating patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Introduce Team Leader of the Day and Coordinator of the Day roles to provide senior support and clear escalation routes.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Use daily SITREP and out-of-hours handover processes to monitor capacity, demand and acuity and escalate urgent staffing pressures.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Increase caseload reviews and triage to prioritise patients with complex, frail, end-of-life or changing clinical needs.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Conduct deteriorating-patient audits and systematically monitor pathway use, clinical observations and NEWS2 compliance across teams.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Bedfordshire and Luton
Concerns raised1
Failure to recognise and escalate 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Agree and implement a common local protocol, including a flowchart, defining healthcare and prison staff roles, responsibilities, escalation and management of suspected illicit-substance influence.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Facilitate mandatory induction training for healthcare staff on detecting and managing suspected illicit-substance influence.
Stated by Northamptonshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2026.
Action
Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Essex
Concerns raised1
Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
This report raised 18 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 restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Newcastle and North Tyneside
Concerns raised1
Failure to recognise the greater role of heart failure in deterioration
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.
Liverpool and the Wirral
Concerns raised1
Failure to obtain timely alternative clinical input when the registered GP is unavailable
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Supervise senior care assistants on obtaining clinical support, including contacting 111 or 999 when residents are unwell and a GP is unavailable.
Stated by Riversdale (Northwest) LimitedStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Arrange local GP registration within 24 hours for new out-of-district residents and obtain 111 advice if they become unwell before registration.
Stated by Riversdale (Northwest) LimitedStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
South Wales Central
Concerns raised5
Delays in recognising acute deterioration in people with learning disabilities
Delays in responding to acute deterioration in people with learning disabilities
Delays in escalating acute deterioration in people with learning disabilities
Lack of familiarity with the use of an acute deterioration recognition tool in Wales
Lack of a specific practice tool for recognising, escalating and responding to potential acute deterioration in people with learning disabilities
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Incorporate annual learning disability health checks into the GP Wales core contract for eligible adult patients.
Stated by Cabinet Secretary for Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Provide additional funding to health boards to embed annual learning disability health checks and support GP practices.
Stated by Cabinet Secretary for Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2025.
Action
Support enhancements with NHS Performance and Improvement to ensure high-quality annual learning disability health checks.
Stated by Cabinet Secretary for Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local authorities or commissioning bodies are responsible for ensuring care workers receive relevant training through individual care plans.
Stated by Cabinet Secretary for Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure to escalate deteriorating patients for medical assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Strengthen verbal handovers during shift changes to support identification and escalation of safety concerns.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 August 2025.
Action
Launch and embed Trust-wide Safety Huddles at BDGH for real-time identification and escalation of safety concerns.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 August 2025.
Worcestershire
Concerns raised1
Failure to recognise post-fall deterioration and seek timely medical assessment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Stated by Green Range LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Action
Provided fall prevention and management training to staff.
Stated by Green Range LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
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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.
