Recurring concern
Failure to reliably recognise and respond to acute clinical deterioration
Pin
Get email alerts
Request correctionFirst reported 24 Sep 2013•Latest report 24 Jun 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
-
Concerns raised1
Failure to act on deterioration or requests for earlier prompt review raised through the flagging process
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of call takers to recognise worsening condition
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 concernsEach 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.4
-
Action
Provide enhanced training to existing Support Call Takers on recognising deterioration and responding appropriately.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Provide enhanced deterioration-recognition training to new Support Call Takers during induction.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Implement a Patient Welfare Procedure requiring Support Call Takers to work with Clinical Navigators to manage waiting calls clinically.
Stated by South East Coast Ambulance Service NHS Foundation Trust
-
Action
Introduce an audit system for Support Call Takers’ work, including audit criteria and scoring.
Stated by South East Coast Ambulance Service NHS Foundation Trust
-
Concerns raised2
Failure to identify, recognise and act upon deteriorating patients
Failure to escalate deteriorating patients for medical review
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 concernsEach 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.6
-
Action
Develop deteriorating-patient protocols tailored to each young person’s care needs.
Stated by EAM Caregroup -
Action
Establish escalation of family, carer or professional concerns to primary care, out-of-hours services or paramedics regardless of nursing observations.
Stated by EAM Caregroup -
Action
Provide clinical-observation training to staff, including basic resuscitation training.
Stated by EAM Caregroup
-
Action
Establish accredited nurse-manager training capacity to deliver clinical-observation training across staff shifts.
Stated by EAM Caregroup -
Action
Implement an updated When to Seek Medical Advice policy, requiring staff acknowledgement and signatures and addressing family concerns.
Stated by EAM Caregroup -
Action
Update the hospital admission and discharge policy to include When to Seek Medical Advice guidance.
Stated by EAM Caregroup
-
Concerns raised1
Failure to recognise and seek help for a deteriorating condition
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 concernsEach 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
Deliver Nutrition and Diabetes Management Training to nursing home staff.
Stated by Adbolton Hall Limited
-
Concerns raised1
Failure to communicate the significance of post-fall deterioration signs to patients’ interpreters or carers
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure to provide clinical or nursing review after deterioration in consciousness
Failure to escalate and act on a deteriorating patient condition
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 concernsEach 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
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
-
Concerns raised1
Failure to identify deterioration during patient transport
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 concernsEach 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
Instruct the provider to produce an action plan addressing the identified patient transport safety measures.
Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care Board -
Action
Review the provider’s action plan at the April 2018 contract and quality meeting, request measurable outcomes, and monitor progress until actions are concluded.
Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Transport records contradict the reported four-hour journey and record no observed deterioration or route deviation.
Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care Board
-
Position
Hospital transfers requiring escalation are handled by the 999 ambulance service, not patient transport staff.
Stated by NHS Staffordshire and Stoke-on-Trent Integrated Care Board
-
Concerns raised2
Failure to recognise residents’ deteriorating condition
Failure to seek and communicate appropriate medical follow-up for deteriorating residents
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 concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Medical advice was sought appropriately, and no urgent referral was recommended or documented by the out-of-hours doctor.
Stated by Southwinds Limited
-
Concerns raised1
Failure to act on or escalate patient deterioration
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 concernsEach 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.4
-
Action
Maintain electronic NEWS scoring linked to bedside vital-sign recording and observation-frequency escalation.
Stated by Northern Care Alliance NHS Foundation Trust -
Action
Update ward safety-huddle content to identify patients requiring hourly urine-output monitoring and address responses to deteriorating NEWS scores.
Stated by Northern Care Alliance NHS Foundation Trust -
Action
Conduct weekly audits of elevated-NEWS escalation to verify compliance with the adult observation policy timeframe.
Stated by Northern Care Alliance NHS Foundation Trust
-
Action
Discuss deterioration-response learning with staff involved and support individual practice learning.
Stated by Northern Care Alliance NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The Hospital at Night model, senior nurse triage and multidisciplinary onsite team provide sufficient out-of-hours prioritisation and care.
Stated by Northern Care Alliance NHS Foundation Trust
-
Concerns raised1
Failure to recognise severe clinical deterioration on consultant ward rounds
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 concernsEach 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
Define critical-care leadership and accountability under the consultant in charge, with consultant-led handover for junior night staff.
Stated by Queen Victoria Hospital NHS Foundation Trust -
Action
Use unified multidisciplinary critical-care documentation and audit its implementation within the enhanced recovery programme.
Stated by Queen Victoria Hospital NHS Foundation Trust -
Action
Monitor the trust’s prospective PEG audit through routine engagement, including adherence to policy and timely escalation of deterioration.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Stated by Department of Health and Social Care
Data last updated 7 September 2026