Recurring concern
Failure to reliably recognise and respond to acute clinical deterioration
- Reports that mention this concern
- 103
- Times this concern has been raised
- 127
- Stated actions linked to this concern
- 169
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 103 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Failure to recognise deteriorating clinical condition
Failure to recognise changing oxygen requirements and heart rate as signs of deterioration
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- East Suffolk and North Essex NHS Foundation Trust
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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East Suffolk and North Essex NHS Foundation Trust
Discuss the case with ward and governance staff to promote recognition of underlying causes of abnormalities in apparently stable patients.
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East Suffolk and North Essex NHS Foundation Trust
Circulate learning on persistent tachycardia and the need for further investigations to identify its underlying cause.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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NHS England
Concerns about care at Colchester General Hospital fall outside NHS England’s remit.
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NHS England
East Suffolk & North Essex NHS Foundation Trust is responsible for responding to concerns about care at Colchester General Hospital.
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East Suffolk and North Essex NHS Foundation Trust
The clinical presentation did not clearly indicate impending acute deterioration from upper gastrointestinal obstruction or grossly abnormal electrolytes.
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Concerns raised1
Insufficient training of community and primary care teams to recognise deterioration in healing fractures
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to recognise the seriousness of a low or unrecordable blood pressure and continue observations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
University Hospitals Birmingham NHS Foundation Trust
Deliver manual blood-pressure training and competency assessment for Emergency Department staff, including escalation and alternative perfusion assessment methods.
-
Department of Health and Social Care
Continue working with NHS England to identify resources needed for healthcare professionals to recognise and respond appropriately to patient deterioration.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
The Trust is responsible for responding directly to concerns about assessing the patient’s low blood pressure.
-
Concerns raised1
Failure to recognise the significance of the first four hours after birth when assessing possible neonatal deterioration
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of Derby and Burton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
University Hospitals of Derby and Burton NHS Foundation Trust
Implement the NEWTT2 framework for newborn assessment, escalation and review.
-
University Hospitals of Derby and Burton NHS Foundation Trust
Amend and implement NEWTT2 guidance to standardise escalation for neonatal respiratory distress.
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Concerns raised1
Delays in medical review of acute clinical deterioration
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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The Trust
Use Nervcentre task lists to communicate outstanding patient tasks between day and night teams during clinical handover.
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The Trust
Provide out-of-hours patient-care coordination through a dedicated Hospital at Night team.
-
Concerns raised1
Failure to review incident management in response to evidence of deterioration during a 999 call
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East of England Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
East of England Ambulance Service NHS Trust
Integrate the Critical Care desk function into all three control rooms to improve identification, monitoring and reassessment of enhanced-care needs.
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East of England Ambulance Service NHS Trust
Publish an article in the weekly AOC staff newsletter reminding staff to actively listen and escalate calls where appropriate.
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East of England Ambulance Service NHS Trust
Address active listening and appropriate call escalation specifically with call handlers during supervision or one-to-one meetings.
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Concerns raised2
Failure to recognise deteriorating patients
Delays in escalating deteriorating patients for acute secondary care intervention
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Nottinghamshire Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
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Nottinghamshire Healthcare NHS Foundation Trust
Scope physical healthcare models across inpatient services and roll the work out across all services.
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Nottinghamshire Healthcare NHS Foundation Trust
Deliver NEWS2 training to all frontline clinical staff required to undertake the assessment.
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Nottinghamshire Healthcare NHS Foundation Trust
Provide clinical supervision through senior Quality Matrons to support NEWS2 practice and continuous learning.
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Nottinghamshire Healthcare NHS Foundation Trust
Introduce scenario-based NEWS2 examples during clinical supervision to assess staff competency around escalation.
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Nottinghamshire Healthcare NHS Foundation Trust
Undertake a further training needs analysis to identify enhancements to frontline knowledge and clinical skills.
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Nottinghamshire Healthcare NHS Foundation Trust
Review and reinforce the emergency medical-call process, requiring staff to call an ambulance when immediate physical-health concerns arise.
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Concerns raised1
Failure to escalate, assess and investigate NEWS-triggered deterioration
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Mid Yorkshire Teaching NHS Trust
- Royal College of Radiologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Mid Yorkshire Teaching NHS Trust
Maintain and improve escalation protocols for recognising and responding to deteriorating patients.
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Mid Yorkshire Teaching NHS Trust
Provide ongoing deterioration-response education to nursing, allied health and junior medical staff.
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Mid Yorkshire Teaching NHS Trust
Provide a 24/7 Deteriorating Adult Response Team for patients meeting deterioration referral criteria.
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Mid Yorkshire Teaching NHS Trust
Augment the deteriorating-patient response service with additional capacity.
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Mid Yorkshire Teaching NHS Trust
Operate the Call 4 Concern patient-safety initiative, connecting ward calls from patients or families to Deteriorating Adult Response Team members.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Royal College of Radiologists
Points 1 and 4 of the concerns are not directly relevant to the RCR’s remit or responsibilities.
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Concerns raised2
Failure to escalate care in response to clearly expressed parental concerns about a deteriorating child
Failure to recognise the severity of a seriously ill child’s condition
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- London North West University Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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London North West University Healthcare NHS Trust
Develop, ratify, disseminate and audit a paediatric examination SOP covering escalation, SBAR handovers, senior opinions and mandatory face-to-face review before discharge.
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London North West University Healthcare NHS Trust
Advise clinicians to seek senior review when caregivers remain concerned after clinical review.
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London North West University Healthcare NHS Trust
Implement the nationally approved Paediatric Early Warning System observation and escalation charts.
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London North West University Healthcare NHS Trust
Operate point-of-care testing for Streptococcus A and respiratory illness within the emergency pathway.
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London North West University Healthcare NHS Trust
Add paediatric cases and learning from pertinent clinical presentations as a standard agenda item for the monthly Deteriorating Patients Group.
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Concerns raised1
Failure to recognise cardiac arrest
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leonard Cheshire Disability
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Leonard Cheshire Disability
Provide sourced vital-signs training information to current clinical staff and new clinical starters.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026