Recurring concern

Unreliable measurement of vital signs during clinical assessments

Get email alerts

Request correction

First reported 3 Jan 2014•Latest report 3 Sep 2025

Definition

What this concern includes

Includes failures to obtain or accurately measure temperature, blood pressure and comparable vital signs when clinically required during patient assessment or care, including failures involving equipment use, omission of measurements or measurement arrangements that leave clinicians without reliable observations.

Not included

Excludes failures limited to recording, communicating or acting on vital signs when the measurements themselves were reliably obtained.
Excludes generic clinical-assessment, staffing, training or equipment deficiencies unless they directly impair measurement of a clinically required vital sign.
Excludes condition-specific monitoring systems, such as early-warning scores, blood-glucose monitoring or neurological observations, where that named system provides the more specific supported boundary.
Excludes non-vital measurements and routine observations where no clinically required measurement or safety consequence is identified.

Reports: 11
Individual concerns: 11
Date range: 2014–2025
Stated actions: 5

Reports 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.

Department of Health and Social Care3

Care Quality Commission2

Royal College of Psychiatrists2

Blackpool Teaching Hospitals NHS Foundation Trust1

Central and North West London NHS Foundation Trust1

gtd healthcare1

Home Office1

Hurst Hall1

Langley Health Centre1

Mitie1

Mitie Care And Custody Limited1

NHS England1

NHS Greater Manchester Integrated Care Board1

NHS North of England Commissioning Support Unit1

NHS Surrey and Sussex Integrated Care Board1

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.

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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Amending regulations to permit homecare agencies to undertake medical or nursing observations is outside CQC’s scope and powers.
  Stated by Care Quality CommissionOutside remit
1. Position
  The Secretary of State for Health and Social Care may be better placed to consider whether regulatory changes are required.
  Stated by Care Quality CommissionRedirects 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
6 Aug2025
Inner North London
Concerns raised1
1. Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Prescribers, not the Department, decide whether medicines can be safely prescribed and must account for relevant national clinical guidance.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jacob Matthew WOODERSON · 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

Jacob Wooderson, who was being treated with Elvanse for ADHD, increased his dosage to 70 mg in August 2024 and subsequently experienced poor sleep and exhaustion before collapsing and dying at home on 23 August 2024. The inquest recorded sudden arrhythmic death syndrome, with Elvanse treatment for ADHD as a contributing factor, although the precise cause of the arrhythmia could not be established. Concerns included inadequate monitoring and documentation of heart rate, blood pressure and medication advice, particularly following dosage increases and during remote consultations.

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
Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations
Wider context from the report
“3) The practice of remote consultations may mean that prescribers are reliant upon patients providing heart rate and blood pressure data outside of the consultation. Consequently, there is the potential for clinical decisions to be based on unreliable observations. ”
Source location
Jacob Matthew WOODERSON · Prevention of Future Deaths report
Page 3 · 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
Prescribers, not the Department, decide whether medicines can be safely prescribed and must account for relevant national clinical guidance.

Verbatim wording from the response
“Ultimately, decisions about what medicines to prescribe are made by the doctor or healthcare professional responsible for that part of the patient’s care, and prescribers are accountable for their prescribing decisions. Prescribers must always satisfy themselves that the medicines they consider appropriate for their patients can be safely prescribed and that they take account of appropriate national guidance on clinical effectiveness – as detailed for ADHD management and Elvanse specifically in the above paragraphs. Prescribers are supported by specialist professional bodies (e.g. Royal Colleges) and held to account professionally by professional regulators, such as the General Medical Council (GMC).”

Source location
Response from Department for Health and Social Care
Page 4 · response
Published 28 August 2025
Open published response
17 Dec2020
Manchester South
Concerns raised1
1. Failure to ascertain temperature during care-home GP assessments
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure appropriate checks that the GP carries basic equipment and updates records at consultation where possible.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
Respondent positions 1
1. Position
  The failure to carry equipment and update records did not impact the patient's outcome.
  Stated by NHS Greater Manchester Integrated Care BoardDisputes the concern
AI-generated summary

Philip Taylor · 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

Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.

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 ascertain temperature during care-home GP assessments
Wider context from the report
“1. Mr Taylor was seen by a GP the day before he died. His risk of dehydration was not recognised. The precise observations of the GP were difficult to ascertain at the inquest for a number of reasons. • The inquest was told that the GP had been called as the care home had concerns about Mr Taylor. However, the GP did not ascertain his temperature because the inquest was told that he did not routinely carry or use a thermometer when he saw patients in a care home. The explanation provided to the inquest was that as a GP he did was not equipped with medical gadgets in the way for example NWAS staff were. • The notes relating to the visit had not been written up until the next day and the GP could not recall all of any observations. It was unclear why that had occurred. ”
Source location
Philip Taylor · 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
Ensure appropriate checks that the GP carries basic equipment and updates records at consultation where possible.

Verbatim wording from the response
“I am mindful that steps taken now cannot undo what happened in this case, and I am satisfied that from a clinical perspective, the failure to carry equipment / update records did not impact on the outcome for this gentleman. However my expectation is that all Stockport GPs do carry basic equipment to enable the recording of clinical observations and for patient records to be updated at the point of consultation, wherever possible. I am sorry that this did not happen in this case and I will ensure that appropriate checks are made to ensure that Dr ████████ adheres to this standard of practice.”

Source location
2020-0289-Response-from-NHS-Stockport-CCG-Redacted
Page 2 · response
Published 7 January 2021
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 failure to carry equipment and update records did not impact the patient's outcome.

Verbatim wording from the response
“I am mindful that steps taken now cannot undo what happened in this case, and I am satisfied that from a clinical perspective, the failure to carry equipment / update records did not impact on the outcome for this gentleman. However my expectation is that all Stockport GPs do carry basic equipment to enable the recording of clinical observations and for patient records to be updated at the point of consultation, wherever possible. I am sorry that this did not happen in this case and I will ensure that appropriate checks are made to ensure that Dr ████████ adheres to this standard of practice.”

Source location
2020-0289-Response-from-NHS-Stockport-CCG-Redacted
Page 2 · response
Published 7 January 2021
Open published response
19 Oct2020
Blackpool and the Fylde
Concerns raised1
1. Failure to take vital signs 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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Douglas OWENS · 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

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

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 take vital signs observations
Wider context from the report
“(3)That the evidence disclosed omissions in the taking of vital signs observations and in the recording of observations in the vital signs observation chart (incorporating the National Early Warning Score). Unless action is taken, there is a risk that any deterioration in the condition of patients which might put their lives at risk will not be identified at the earliest opportunity. ”
Source location
Douglas OWENS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Aug2019
London (West)
Concerns raised1
1. Failure to wake, assess and take vital signs of a sleeping patient at risk
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amir Siman-Tov · 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

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

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 wake, assess and take vital signs of a sleeping patient at risk
Wider context from the report
“11. The night nurse on duty at around 2100 noted that Mr Siman-Tov was sleeping and snoring. He made no attempt to wake him, check him or take his vital signs. This put Mr Siman-Tov at risk. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report
2 May2019
Inner South London
Concerns raised1
1. Failure to measure vital signs
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Royston Kemp · 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

Mr Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.

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 measure vital signs
Wider context from the report
“A nurse working at Marlborough Court Care Home, who has already been referred to the NMC assessed this frail elderly resident whose leg caused concern to care assistants. In doing so her evidence concerned the coroner was: 1) She found one leg more swollen than the other and of a different temperature but took no action 2) She failed to establish the care assistant’s concern or whether she had met the concern before or after her assessment 3) She failed to measure Vital Signs 4) She failed to escalate to medical care or refer, in the process failed to enable a diagnosis of fractured femur to be made. ”
Source location
Mr Royston Kemp · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 May2017
London (West)
Concerns raised1
1. Lack of regular monitoring and documentation of physical vital signs in acute mental health settings
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.
  Stated by NHS EnglandStated in progress
AI-generated summary

Alice Amaryllis Gibson-Watt (“Alice”) · 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

Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

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 regular monitoring and documentation of physical vital signs in acute mental health settings
Wider context from the report
“This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. I am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. I am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have seen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ”
Source location
Alice Amaryllis Gibson-Watt (“Alice”) · Prevention of Future Deaths report
Page 3 · 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
Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.

Verbatim wording from the response
“• In parallel, NHS England continues to support the ongoing inspection and regulation of mental health in-patient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS.”

Source location
2017-0163-Response-by-NHS-England
Page 2 · response
Published 17 August 2017
Open published response
20 Aug2015
Manchester South
Concerns raised1
1. Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Elsie Clarke · 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

Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

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 Out of Hours doctors to carry or wear a watch for vital-sign assessment
Wider context from the report
“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”
Source location
Elsie Clarke · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Aug2014
South Lincolnshire
Concerns raised1
1. Failure to use semi-automatic thermometers correctly for measuring body temperature
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Iris May GRIMWOOD · 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

Iris May GRIMWOOD, aged 80, died at Pilgrim Hospital on 8 October 2013 as a result of progressive neurological disease. Concerns were raised about difficulties providing the nursing care she needed, including errors in using semi-automatic thermometers and an attempted application of an antifungal ointment prescribed for oral thrush to her genital region.

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 use semi-automatic thermometers correctly for measuring body temperature
Wider context from the report
“Evidence from medical staff at Pilgrim Hospital and members of Iris's family included expressions of concern that there were difficulties in providing the level of nursing care that Iris needed. Evidence was also given that mistakes were made in the use of semi-automatic thermometers for measuring body temperature and an episode was described where a nurse attempted to apply an antifungal ointment to Iris's genital region, this having been prescribed for the treatment of oral thrush, before being stopped by a family member. The medical staff attributed these problems to less than optimal numbers of nursing staff, compounded by difficulties in recruitment and retention of nursing staff as well as problems with funding training. ”
Source location
Iris May GRIMWOOD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Jul2014
Surrey
Concerns raised1
1. Lack of GP routine vital sign monitoring when weight loss is a concern
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Co-author a revised MARSIPAN guideline addressing physical risk monitoring in eating disorders.
  Stated by Royal College of PsychiatristsStated completed
2. Action
  Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.
  Stated by Woodlands SurgeryStated planned
3. Action
  Objectively document weight loss through serial weight measurements.
  Stated by Woodlands SurgeryStated planned
AI-generated summary

Clare Serena Anke COOPER · 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

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

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 GP routine vital sign monitoring when weight loss is a concern
Wider context from the report
“3. Lack of GP routine vital sign monitoring e.g. heart rate, blood pressure and weight measurement when weight loss is a concern with a lost opportunity to assess the severity of weight loss. ”
Source location
Clare Serena Anke COOPER · Prevention of Future Deaths report
Page 3 · 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
Co-author a revised MARSIPAN guideline addressing physical risk monitoring in eating disorders.

Verbatim wording from the response
“The specific issue of robust EDS proformas is best tackled through the MARSIPAN Guidelines of the Royal College of Physicians and the Royal College of Psychiatrists, which address physical risk monitoring in eating disorders. I co-authored the original guideline, and have co-authored a revised guideline, but the lead in this has been ████████ whose expertise in risk assessment in eating disorders is well recognised.”

Source location
2014-0345-Response-by-Royal-College-of-Psychiatrist
Page 2 · response
Published 25 July 2014
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
Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.

Verbatim wording from the response
“We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 2 · response
Published 25 July 2014
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
Objectively document weight loss through serial weight measurements.

Verbatim wording from the response
“We have all agreed that all patients should have a proper assessment of their history and a full examination should be done. Routine vital signs should be recorded if they are clinically relevant. If a patient presents with weight loss then the weight loss needs to be objectively documented with serial weight measurements.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 2 · response
Published 25 July 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of ability and equipment for carers to carry out basic observations of unwell clients

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to ascertain temperature during care-home GP assessments

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to take vital signs observations

Concerns raised1

Failure to wake, assess and take vital signs of a sleeping patient at risk

Concerns raised1

Failure to measure vital signs

Concerns raised1

Lack of regular monitoring and documentation of physical vital signs in acute mental health settings

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

Concerns raised1

Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment

Concerns raised1

Failure to use semi-automatic thermometers correctly for measuring body temperature

Concerns raised1

Lack of GP routine vital sign monitoring when weight loss is a 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

Respondent positions 2

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 1

Actions described in response 3