Recurring concern

Failure to carry out required neurological observations

First to latest report 28 Feb 2014 — 12 Jun 2026

Reports that mention this concern
26
Times this concern has been raised
33
Stated actions linked to this concern
55

What this concern includes

Includes failures of the neurological-observation process, including dedicated planning, continuity, staff competence, performance, accuracy, recording and adherence to applicable guidance where these failures concern neurological observations.

What is not included
  • Excludes generic clinical or vital-sign observations that are not specifically neurological observations.
  • Excludes generic training, staffing, documentation or monitoring deficiencies unless the report directly ties them to the neurological-observation process.
  • Excludes failures of escalation or treatment that are not part of carrying out or interpreting required neurological observations.
  • Excludes unrelated observation processes, including psychiatric, prisoner, postoperative or neonatal observations, unless neurological observations are explicitly involved.

Reports and published responses 26 reports

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

  1. Exeter and Greater Devon

    AI-generated summary

    Robert Alan JONES · 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

    Robert Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.

    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 record neurological observations correctly and at the minimum recommended frequency

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

    Source location

    Robert Alan JONES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Use of an out-of-date post-falls checklist lacking required neurological observation details

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”

    Source location

    Robert Alan JONES · 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

    Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.

    Verbatim wording from the response

    “(1) Revise the Trust’s falls policy to include the recommended frequency and duration of neurological observations based on NICE guidance for patients where head injury has occurred or cannot be ruled out, and inclusion of relevant history of falls in handovers of care.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 January 2015

    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

    Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.

    Verbatim wording from the response

    “(3) Ensure delivery of targeted training on performing neurological observations for nursing staff at South Molton Community Hospital and as a general communication across the trust.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 2 · response
    Published 21 January 2015

    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

    Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.

    Verbatim wording from the response

    “To support the actions detailed above, the Trust will issue a Patient Safety Alert, which will communicate the need for neurological observations when a head injury has occurred or cannot be ruled out, completion of the post falls checklist, to include the frequency and duration of observations, to ensure the post falls checklist is filed with the patient’s observation chart for ease of access for all Multi-Disciplinary Team members, and to ensure that information relating to falls risk or actual falls is included in safety briefings and bedside handover. Patient Safety Alerts are disseminated across the whole Trust to clinical and managerial leads.”

    Source location

    2015-0018-Response-by-Northern-Devon-Healthcare-NHS-Trust
    Page 2 · response
    Published 21 January 2015

    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 recommended safety actions are primarily the responsibility of the hospital trust.

    Verbatim wording from the response

    “The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

    Source location

    2015-0068-Response-by-The-Health-Centre
    Page 1 · response
    Published 21 January 2015

    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 hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.

    Verbatim wording from the response

    “The recommended actions are primarily the responsibility of the hospital trust: I enclose a copy of their Action Plan which I have just received from ████████, Matron of South Molton Community Hospital and which I believe satisfactorily addresses all your concerns and recommended actions.”

    Source location

    2015-0068-Response-by-The-Health-Centre
    Page 1 · response
    Published 21 January 2015

    Open published response

  2. Inner North London

    AI-generated summary

    Thomas Charles 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

    Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

    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 perform neurological observations after significant hyperglycaemia

    Wider context from the report

    “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic. When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff. ”

    Source location

    Thomas Charles TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Irshad ALI · 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

    Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his 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 perform neurological observations before discharge

    Wider context from the report

    “3. The consultant in charge of Mr Ali’s care stipulated that his junior medical colleagues should perform neurological observations before Mr Ali could be discharged, yet this did not take place. The sister in charge told me that she asked the registrar if Mr Ali was neurologically stable enough to be discharged, and she said yes. ”

    Source location

    Irshad ALI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 record post-fall neurological observations

    Wider context from the report

    “2. Though the senior sister looking after Mr Ali on the morning of 25 March assured me that neurological observations were carried out hourly after his fall, there was no record of this. Again, the chart appears to have gone missing. ”

    Source location

    Irshad ALI · 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 nurses with neurological-observation training through the Critical Care Outreach Team.

    Verbatim wording from the response

    “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 29 August 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

    Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.

    Verbatim wording from the response

    “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 29 August 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

    Include documentation and falls management in induction for new medical trainees.

    Verbatim wording from the response

    “Senior medical staff have confirmed that the induction for new medical trainees now includes a section on documentation and management of falls, emphasising the requirement to document actions in the medical records.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 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

    Hold twice-daily safety briefings highlighting the Trust falls protocol.

    Verbatim wording from the response

    “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 29 August 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

    Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.

    Verbatim wording from the response

    “To ensure that the Trust falls protocol is being complied with, twice daily safety briefings will be held to highlight the falls protocol. Nursing staff have been reminded that the nurse in charge of shift has responsibility for ensuring the correct procedure is followed and documented in the medical notes. Training for nurses in neurological observations is being provided by the Critical Care Outreach Team. Effectiveness will be measured by audit of nurses’ understanding of the falls policy and documentation in the care plan, their understanding of neurological observations, and competence in the performance of neurological observations.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 29 August 2014

    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

    Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.

    Verbatim wording from the response

    “The missing neurological observation chart has been located and it confirms that appropriate neurological observations were carried out after Mr Ali’s fall. This chart had been inadvertently misfiled.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 2014

    Open published response

  4. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Vivian Herbert HUNT · 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

    Vivian Herbert HUNT, an 84-year-old patient on the Mental Health ward, fell in his hospital room on 3 April 2014 after a similar fall the previous day, sustained a facial injury, deteriorated, and later died from a brain bleed. The report raised concern that no neurological observations were made during specified periods after the falls and facial injury.

    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 make neurological observations after falls and facial injury

    Wider context from the report

    “(1) Despite the fall he suffered on 2nd April and despite suffering a clear injury to his face in the fall on 3rd April 2014, no neurological observations were made of him between 5am on 3rd April and between 12:30 and 13:15pm that day. ”

    Source location

    Vivian Herbert HUNT · Prevention of Future Deaths report
    Page 1 · 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

    Implement compliance with neurological investigations following head injury.

    Verbatim wording from the response

    “2. Actions implemented”

    Source location

    2014-0363-Response-by-University-Health-Board
    Page 1 · response
    Published 6 August 2014

    Open published response

  5. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 carry out directed neurological and physical observations after a fall

    Wider context from the report

    “2. The staff at the care home accepted the responsibility of Mr Godfrey’s care following the paramedic’s assessment. They agreed to observe Mr Godfrey during the night. The actual checks carried out by the staff were not in accordance with the direction given by the paramedic. The senior care worker confirmed that she did not examine the swelling or check for alertness. 3. The Deputy Manager who gave evidence at the inquest confirmed that the checks carried out by the staff were not in her view appropriate. She would have expected the pupils to have been checked and checks to ensure that the patient was alert and orientated. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Oxfordshire

    AI-generated summary

    Peter Norman Nott · 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

    Peter Norman Nott, who had Parkinson's disease and was at very high risk of falls, experienced an unwitnessed fall at a nursing home on 2 September 2013 and died on 8 September 2013 from a subdural haemorrhage and Parkinson's disease. The concerns included that neurological observations after the fall were not undertaken beyond a simple visual examination and that inaccurate information about his consciousness was passed to 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 undertake neurological observations and further examination after a fall

    Wider context from the report

    “Although staff at the care home were attentive to Dr Norman Nott after his fall, and advice was sought from Dr Norman Nott’s GP, it was accepted in questioning that the trained staff should have undertaken neurological observations over and above a simple visual examination. The need to undertake further examination was heightened when the length of time Dr Norman Nott remained lying down (although conscious) and certainly as this time extended into the afternoon. ”

    Source location

    Peter Norman Nott · 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

    Review policies and procedures for managing residents after unwitnessed falls.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 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

    Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.

    Verbatim wording from the response

    “The organisation has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. This procedure will be cascaded to all clinical staff with instructions that should a resident fall and it is unwitnessed, then nursing staff or the person in charge of a residential home, should commence neurological observations. These will be recorded using the Glasgow Coma Scale and incorporated into a resident’s care plan.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 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

    Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.

    Verbatim wording from the response

    “This procedure will be reinforced during staff meetings and any individual training needs will be monitored through the supervision, learning and development programme. Basic competencies for head injury care will be reviewed with all clinical staff and the person in charge of our residential home.”

    Source location

    2014-0229-Response-by-Elizabeth-Finn-Homes
    Page 1 · response
    Published 28 February 2014

    Open published response

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

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Data last updated 7 September 2026