Recurring concern
Failure to maintain required continuous patient observation
- Reports that mention this concern
- 21
- Times this concern has been raised
- 22
- Stated actions linked to this concern
- 31
What this concern includes
Includes failures of a dedicated continuous, within-eyesight, 1:1, or equivalent patient-observation process, regardless of whether the failure arises from staff conduct, unsuitable facilities, inadequate staffing, or use of an ineffective observation method.
What is not included
- Excludes observation requirements that are not continuous or not a dedicated patient-safety observation process.
- Excludes generic staffing, training, documentation, policy, or environmental deficiencies unless they directly cause failure of required continuous patient observation.
- Excludes monitoring of non-patient subjects, such as weapons, equipment, records, or communications.
- Excludes unrelated patient-location, contact, or assessment failures where continuous observation is not the required control.
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 21 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to maintain required supervision when staff attend to other patients
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Mid and South Essex 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.1
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Mid and South Essex NHS Foundation Trust
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
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Concerns raised1
Failure to provide constant eyesight observations in a patient’s bedroom
This report raised 30 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Essex Partnership University 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.4
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Essex Partnership University NHS Foundation Trust
Implement patient-specific engagement and observation plans and maintain a maximum allocation of three level-two patients to one staff member in CAMHS.
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Essex Partnership University NHS Foundation Trust
Implement daily handover checks and weekly audits to verify completion and appropriateness of patient observations.
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Essex Partnership University NHS Foundation Trust
Implement electronic observations, staff training videos, engagement plans, and revised observation policies and procedures.
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Essex Partnership University NHS Foundation Trust
Strengthen observation monitoring through nurse-in-charge checks, handover checks, compliance audits, escalation, and staff accountability processes.
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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Essex Partnership University NHS Foundation Trust
Existing systems are considered robust enough to identify missed observations and ensure appropriate follow-up action with staff.
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Concerns raised1
Failure to maintain effective 1:1 or within-eyesight observations
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East London 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.3
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East London NHS Foundation Trust
Update mobile-phone policy requirements for staff working in clinical areas.
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East London NHS Foundation Trust
Deliver shared learning to unit staff on mobile-phone use while on duty.
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East London NHS Foundation Trust
Introduce CCTV auditing of recorded observations after completing staff training on footage access.
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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East London NHS Foundation Trust
No further action is considered necessary because considerable work has addressed the identified concerns.
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Concerns raised1
Failure to direct staff to the need for 1:1 monitoring
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Care Quality Commission
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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Care Quality Commission
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
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Concerns raised1
Failure to maintain required nurse sight or sound for Level 2 EICO observations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- South Tyneside and Sunderland 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.3
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South Tyneside and Sunderland NHS Foundation Trust
Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
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South Tyneside and Sunderland NHS Foundation Trust
Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
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South Tyneside and Sunderland NHS Foundation Trust
Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
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Concerns raised1
Failure to ensure continuous suitably qualified staff observation after Olanzapine depot injections
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- North London 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.1
-
North London NHS Foundation Trust
Book an additional qualified staff member for inpatient olanzapine depot administrations to prepare, administer and deliver three-hour post-administration observations.
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Concerns raised1
Failure to maintain continuous sight of patients during one-to-one observations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East London 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.3
-
East London NHS Foundation Trust
Update the mobile phone policy to prohibit personal mobile phone use during clinical shifts.
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East London NHS Foundation Trust
Increase lead Nurse or Matron night-shift visits to twice monthly for three months and observe compliance with clinical standards and the mobile phone policy.
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East London NHS Foundation Trust
Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
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Concerns raised1
Failure to maintain observable bay nursing because of insufficient staff time and competing ward demands
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- 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.1
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NHS England
Implement the Long Term Workforce Plan priorities to improve training, staff retention and workforce sustainability for inpatient care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Care Quality Commission
Registered providers, rather than CQC, must determine how to implement detailed standards and good practice for patient safety.
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Care Quality Commission
CQC does not consider bay nursing itself a national patient-safety issue; staffing pressures, including inadequate levels, create the safety risk.
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Concerns raised1
Failure to provide continuous in-view observation for Level 4 enhanced care patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Aneurin Bevan University LHB
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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Aneurin Bevan University LHB
The day room cannot always be used for patient cohorting during periods of extreme demand.
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Concerns raised1
Failure to provide constant and effective nursing observation
This report raised 7 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026