Recurring concern

Unreliable measurement of vital signs during clinical assessments

First to latest report 3 Jan 2014 — 3 Sep 2025

Reports that mention this concern
11
Times this concern has been raised
11
Stated actions linked to this concern
5

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.

What is 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 and published responses 11 reports

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

  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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026