Recurring concern
Failure to maintain required continuous patient observation
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Request correctionFirst reported 7 Apr 2014•Latest report 27 May 2026
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.
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.
- Reports
- 21
- Individual concerns
- 22
- Date range
- 2014–2026
- Stated actions
- 31
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.
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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.
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
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Action
Implement enhanced supervision and engagement policy with risk-level assessment, staffing escalation, supervision handovers, daily review and family or carer involvement.
Stated by Mid and South Essex NHS Foundation Trust
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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.
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
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Action
Implement patient-specific engagement and observation plans and maintain a maximum allocation of three level-two patients to one staff member in CAMHS.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Implement daily handover checks and weekly audits to verify completion and appropriateness of patient observations.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Implement electronic observations, staff training videos, engagement plans, and revised observation policies and procedures.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Strengthen observation monitoring through nurse-in-charge checks, handover checks, compliance audits, escalation, and staff accountability processes.
Stated by Essex Partnership University NHS Foundation Trust
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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Position
Existing systems are considered robust enough to identify missed observations and ensure appropriate follow-up action with staff.
Stated by Essex Partnership University NHS Foundation Trust
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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.
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
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Action
Update mobile-phone policy requirements for staff working in clinical areas.
Stated by East London NHS Foundation Trust -
Action
Deliver shared learning to unit staff on mobile-phone use while on duty.
Stated by East London NHS Foundation Trust -
Action
Introduce CCTV auditing of recorded observations after completing staff training on footage access.
Stated by East London NHS Foundation Trust
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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Position
No further action is considered necessary because considerable work has addressed the identified concerns.
Stated by East London NHS Foundation Trust
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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.
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
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Position
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality Commission
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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.
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
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Action
Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
Stated by South Tyneside and Sunderland NHS Foundation Trust
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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.
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
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Action
Book an additional qualified staff member for inpatient olanzapine depot administrations to prepare, administer and deliver three-hour post-administration observations.
Stated by North London NHS Foundation Trust
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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.
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
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Action
Update the mobile phone policy to prohibit personal mobile phone use during clinical shifts.
Stated by East London NHS Foundation Trust -
Action
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.
Stated by East London NHS Foundation Trust -
Action
Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
Stated by East London NHS Foundation Trust
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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.
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
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Action
Implement the Long Term Workforce Plan priorities to improve training, staff retention and workforce sustainability for inpatient care.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Registered providers, rather than CQC, must determine how to implement detailed standards and good practice for patient safety.
Stated by Care Quality Commission
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Position
CQC does not consider bay nursing itself a national patient-safety issue; staffing pressures, including inadequate levels, create the safety risk.
Stated by Care Quality Commission
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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.
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
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Position
The day room cannot always be used for patient cohorting during periods of extreme demand.
Stated by Aneurin Bevan University LHB
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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.
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.
Data last updated 7 September 2026