Recurring concern

Unreliable physiological observation and trend monitoring

First to latest report 9 Jul 2014 — 3 Sep 2025

Reports that mention this concern: 4
Times this concern has been raised: 4
Stated actions linked to this concern: 2

What this concern includes

Includes poor or absent basic physiological observations and failure to compare readings over time to identify clinically important trends, outside a named scoring or condition-specific monitoring system.

What is not included

Excludes EWS, NEWS and other named early-warning scoring failures, which belong to the dedicated Early Warning Score parent.
Excludes condition-specific monitoring such as CTG, glucose or neurological observations where that named control supplies the more faithful boundary.
Excludes escalation failure after complete physiological trends have been reliably recognised and communicated.

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

Reports about this concern sent to each recipient.

BrisDoc Healthcare Services Limited1

Bristol NHS Foundation Trust1

Care Quality Commission1

Cwm Taf Morgannwg University Local Health Board1

Department of Health and Social Care1

National Institute for Health and Care Excellence1

Prince Charles Hospital (Merthyr Tydfil)1

Sunflower House, Partington1

Reports and published responses 4 reports

See individual reports that have raised this concern, and the actions taken in response

3 Sep2025
Manchester South
Concerns raised1
1. Lack of ability and equipment for carers to carry out basic observations of unwell clients
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Care Quality Commission
Respondent positions 2
1. Care Quality Commission
  Amending regulations to permit homecare agencies to undertake medical or nursing observations is outside CQC’s scope and powers.
  Outside remit
1. Care Quality Commission
  The Secretary of State for Health and Social Care may be better placed to consider whether regulatory changes are required.
  Redirects responsibility
AI-generated summary

Margaret Bailey · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margaret Bailey, who was bed-bound and wholly dependent on personal care, became unwell at home on 17 December 2023, later vomited while resting in bed, and was found unresponsive. The medical cause of death was aspiration of gastric contents following an episode of vomiting. Concerns included the absence of a triage algorithm for calls reporting that a client was unwell and the lack of equipment or ability to take basic observations, including a temperature reading.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of ability and equipment for carers to carry out basic observations of unwell clients
Wider context from the report
“2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine. ”
Source location
Margaret Bailey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amending regulations to permit homecare agencies to undertake medical or nursing observations is outside CQC’s scope and powers.

Verbatim wording from the response
“In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.”

Source location
Response from Care Quality Commission
Page 4 · response
Published 5 September 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Secretary of State for Health and Social Care may be better placed to consider whether regulatory changes are required.

Verbatim wording from the response
“In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.”

Source location
Response from Care Quality Commission
Page 4 · response
Published 5 September 2025
Open published response
10 Apr2018
Manchester North
Concerns raised1
1. Poor standard of basic physiological observation and monitoring
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

EAM Caregroup
Stated actions 2
1. EAM Caregroup
  Provide clinical-observation training to staff, including basic resuscitation training.
2. EAM Caregroup
  Establish accredited nurse-manager training capacity to deliver clinical-observation training across staff shifts.
AI-generated summary

Miss Lea Louise Hunsley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lea Hunsley, who had profound cerebral palsy and complex healthcare needs, became increasingly unwell while in respite care on 9 July 2016 and died after cardio-respiratory arrest at Wythenshawe Hospital Emergency Department shortly after midnight on 10 July 2016. The report identified missed opportunities to assess, escalate and intervene, and raised concerns about the facility’s lack of protocols, staff’s ability to recognise deterioration, inadequate observations and monitoring, failure to use care records appropriately, and insufficient action following a CQC inspection.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor standard of basic physiological observation and monitoring
Wider context from the report
“2. Registered Nurse/s and Carers at EAM: i) lack the ability to identify, recognise and act upon the deteriorating patient; ii) in this case, did not escalate for medical review (no policy/protocol exists for the same); iii) demonstrated a poor standard of basic (physiological) observation and monitoring & iv) failed to read and use the care records appropriately (in particular, the RN did not read important/critical entries on the 9th at all). ”
Source location
Miss Lea Louise Hunsley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide clinical-observation training to staff, including basic resuscitation training.

Verbatim wording from the response
“• Staff have undertaken clinical observation training.”

Source location
2018-0101-Response-by-EAM-Care-Group
Page 3 · response
Published 17 June 2018
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish accredited nurse-manager training capacity to deliver clinical-observation training across staff shifts.

Verbatim wording from the response
“• Nurse managers/seniors have received accredited train the trainer presentation skills course and have had training to deliver accredited clinical observations training ourselves. This will ensure it is delivered to staff at times that suit our needs, enabling more staff to access training.”

Source location
2018-0101-Response-by-EAM-Care-Group
Page 3 · response
Published 17 June 2018
Open published response
18 Apr2017
Avon
Concerns raised1
1. Failure of front-door ED streaming to include basic physiological measurements
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Lee BIRTWISTLE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of front-door ED streaming to include basic physiological measurements
Wider context from the report
“1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements. ”
Source location
David Lee BIRTWISTLE · Prevention of Future Deaths report
Page 1 · concerns
Open source report
9 Jul2014
Cardiff & the Vale of Glamorgan
Concerns raised1
1. Failure to monitor physiological trends over time
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas George Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to monitor physiological trends over time
Wider context from the report
“(1) The inquest revealed the importance of observing physiological trends in the patient’s condition, rather than observing readings on a “snap shot” basis. The Coroner considers that comprehensive time series data would have provided clinicians with a sounder platform for assessing Thomas. Can the Chief Executive confirm that this will be the practice at PCH? ”
Source location
Thomas George Smith · Prevention of Future Deaths report
Page 2 · concerns
Open source report