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.
Manchester South
Concerns raised1
Failure to flag deteriorating patients during handover
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.
Sefton St Helens & Knowsley
Concerns raised1
Failure to escalate patients’ deterioration and pain
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.
Inner North London
Concerns raised1
Failure to recognise cardiac arrest
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
Action
Have the Internal Lead Inspector attend Basic Life Support training to assess its quality and efficacy.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Essex
Concerns raised1
Failure of staff clinical judgement to recognise the need for urgent medical attention in critically ill people
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised3
Delays in recognising declining patient condition
Failure to provide timely access to the Duty Doctor for deteriorating patients
Delays in calling paramedics for 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Redistribute NEWS2 quick-reference guides across inpatient sites and directorates.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2022.
Action
Deploy handheld devices for electronic NEWS2 recording, automatic scoring and escalation alerts across Adult Mental Health inpatient areas.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2022.
Action
Deliver comprehensive NEWS2, anaphylaxis and emergency-treatment training with scenario-based exercises for inpatient staff.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022.
Action
Review the Hospital Life Support lesson plan to confirm adequate coverage and competency assessment for NEWS2, anaphylaxis and emergency treatment.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022.
Action
Review the Rapid Tranquillisation Policy, consult an external intensivist and define assessment, learning and development requirements for patients who fall asleep afterward.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2022.
Action
Implement a dedicated NHS wireless network enabling junior doctors’ smartphones to use Wi-Fi calling at identified Kingsmill locations, and distribute user guidance.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2022.
Action
Agree priority-one ambulance responses for emergencies from Mental Health units until the hospital crash process is operational.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A crash bleep was discounted because the duty doctor covered multiple sites and could not provide an immediate response.
Stated by Nottinghamshire Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire Eastern
Concerns raised1
Delay in assessing deterioration
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.
Inner South London
Concerns raised1
Inadequate care planning for monitoring and observations after clinical 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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Provide enhanced nursing observation through the 24-hour Critical Care Outreach Team for patients managed outside critical care.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2021.
Action
Apply nationally derived critical-care admission criteria, with urgent intensive-care review within 60 minutes and admission or ward-management advice.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2021.
Action
Provide immediate critical-care doctor and outreach-nurse support, continuous trained staffing in the safest available area, and transfer to critical care when a bed becomes available.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2021.
Inner North London
Concerns raised1
Unclear use of the NEWS2 scoring system and absence of an effective alternative monitoring system
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
Use NEWS2 to support identification of deteriorating patients and clinical decision-making.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Action
Deliver a service-improvement programme at HMP Pentonville to embed appropriate NEWS2 use, including deteriorating-patient training and distribution of quick-reference cards.
Stated by Practice Plus GroupStated plannedThe respondent said that this action was planned when they made their response on 9 July 2021.
Action
Develop and communicate guidance for monitoring patients who test positive for COVID-19 in custodial settings.
Stated by Practice Plus GroupStated completedThe respondent said that this action was complete when they made their response on 9 July 2021.
Norfolk
Concerns raised1
Failure to promptly recognise and respond to respiratory distress or cardiac arrest during patient transport
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide basic life-support and CPR training to all patient-conveying staff, including drivers, completing internal training as external certificates expire.
Stated by Premier Rescue Ambulance Service LtdStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2021.
Action
Implement a transport policy refusing patients who are not awake and responsive, requiring medical fitness confirmation and medication details for transfer risk assessment.
Stated by Premier Rescue Ambulance Service LtdStated completedThe respondent said that this action was complete when they made their response on 2 June 2021.
Inner South London
Concerns raised1
Failure to recognise snoring as a potential sign of partial airway obstruction requiring medical attention in people with reduced consciousness
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
Develop and provide a vulnerability learning programme supporting consistent identification of hidden medical conditions and other risks requiring intervention.
Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 1 March 2021.
Action
Align officers’ first-aid training with Metropolitan Police guidance on snoring, airway obstruction, jaw thrust, and breathing monitoring.
Stated by City of London PoliceStated plannedThe respondent said that this action was planned when they made their response on 1 March 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The programme cannot provide detailed training covering every medical emergency or policing context because officers attend a wide range of incidents.
Stated by College of PolicingUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Chief Officers may add medical training where local force risk assessments identify a critical need, under local clinical governance advice.
Stated by College of PolicingRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
