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
Lack of continuous observation sufficient to enable prompt medical assistance
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 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.
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Concerns raised1
Failure to ensure Level 3 constant “within eyesight” observations are conducted by direct visual observation
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.
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Concerns raised2
Unclear Royal College of Nursing instructions on continuous observation during iron infusions
Unclear instructions on continuous observation during iron infusions
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.
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 provide constant visual observation after central venous catheter removal
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
Issue an advisory alert to NHS England highlighting haemorrhage-prevention precautions and post-procedure observation and supervision.
Stated by Caroline Dinenage MP -
Action
Review and develop Trust-wide CVC documentation, guidance, checklists and electronic patient-record materials through a multidisciplinary task group.
Stated by Sir David Dalton -
Action
Require pre-removal CVC bleeding-risk assessment and senior medical review of observation arrangements for patients identified as high risk.
Stated by Sir David Dalton
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
Universal one-hour direct observation after CVC removal would not assure prevention of haemorrhage and could create risks to other patients.
Stated by Sir David Dalton
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Concerns raised1
Insufficient ward capacity for patients requiring continuous observation
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.
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Concerns raised1
Failure to keep patients presenting with current self-harm attempts and suspected drug use within eyesight at all times
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.1
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Action
Develop a standard operating procedure for escalating patients who cannot be deterred from leaving before assessment and immediately informing police.
Stated by Royal Free London NHS Foundation Trust
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Concerns raised1
Failure to maintain required arm’s length 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.
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
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Action
Correct staff understanding that the specialist care record applies to patients requiring constant observation, including neurological patients.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Hold L8AW nursing study days covering deprivation of liberty, falls prevention, one-to-one care, end-of-life care and documentation.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
Stated by University Hospitals Sussex NHS Foundation Trust
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Action
Inform bank staff about observation policy and documentation requirements for one-to-one care.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Run refresher teaching for healthcare assistants on one-to-one care requirements.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Audit every patient requiring constant observation and collate the findings for subsequent learning and action.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to initiate appropriate one-to-one supervision and observations
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.2
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Action
Introduce Safety Huddles at the start of ward and departmental shifts to discuss incidents, safety issues and enhanced observation needs.
Stated by Pennine Acute Hospitals NHS Trust -
Action
Introduce the Enhanced Patient Observation Policy to guide safe supervision and observation of adult in-patients.
Stated by Pennine Acute Hospitals NHS Trust
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Concerns raised1
Failure to maintain effective bathing observations for patients with epilepsy
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.2
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Action
Finalise and ratify the Trust-wide protocol for safe bathing and showering of people with epilepsy.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Collate results from epilepsy, bathing-risk and physical-health audits to inform further improvements.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised1
Failure to conduct timely and continuous patient observations
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
Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Data last updated 7 September 2026