Recurring concern

Unreliable measurement of vital signs during clinical assessments

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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

Distinct published reports

Individual concerns
11

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
5

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.

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.

  1. Gateshead and South Tyneside

    AI-generated summary

    Keith Fleming · 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

    Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.

    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 and record community patients’ vital signs

    Wider context from the report

    “The care plan devised during this period of community nursing care did identify a need to record temperature and blood pressure readings. Unfortunately these readings were not carried out and accordingly were not recorded. Physical symptoms were noted but only on a generalized – impressionistic basis - tiredness, responsiveness to questions and discussion – level of activity and mobility – diet. ”

    Source location

    Keith Fleming · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026