First reported 28 Feb 2014•Latest report 12 Jun 2026
Definition
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.
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
26
Distinct published reports
Individual concerns
33
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
55
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.
Cardiff & Vale University LHB3
Office of the Chief Coroner3
Barts Health NHS Trust2
Care Quality Commission2
Cwm Taf Morgannwg University Local Health Board2
Kent and Medway Mental Health NHS Trust2
Royal London Hospital2
Welsh Government2
Bedfordshire Hospitals NHS Foundation Trust1
Bupa Care Homes1
Bupa UK Provision1
Chief Executive
Northern Care Alliance
Salford Royal Hospital1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Doncaster Royal Infirmary1
East Kent Hospitals University NHS Foundation Trust1
NHS trust15
Local health board6
Healthcare site4
Type not available4
Coronial office3
Multi-service care provider3
Devolved government2
Health and social care service regulator2
English metropolitan district council1
Health and care professional regulator1
Integrated care board1
Nursing home1
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.
Manchester North
Concerns raised1
Neurological observations performed too infrequently or discontinued while a second CT scan is pending
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.8
Action
Complete final review and approval of the head-injury Neurological Observation Care Plan.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
Action
Disseminate the approved head-injury Neurological Observation Care Plan across the Trust with supporting communications.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 August 2026.
Action
Submit the amended Head Injury Policy and Neurological Observations Care Plan for approval and distribute them across the Trust.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2026.
Action
Implement the single NCA observation policy with additional neurological-observation guidance and include it in standard nursing training.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Provide mandatory head-injury and trauma-care training, including neurological-observation requirements, to relevant nursing staff.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Display posters across clinical areas highlighting frequent neurological observations and documentation when observations cease.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Conduct monthly audits of neurological observations and care plans, sharing results and learning with staff for real-time feedback.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
Action
Deliver reflective learning with involved medical and nursing staff and share incident learning through team safety huddles.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
South Yorkshire (Eastern)
Concerns raised1
Lack of a clear plan for the frequency and duration of neurological observations following a fall
This report raised 4 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Embed requirements for attending doctors to document individualised post-fall neurological observation plans covering frequency, duration, review and escalation criteria.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Kent and Medway
Concerns raised1
Failure to undertake structured neurological observations
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.
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.5
Action
Implement improvements to electronic documentation of neurological observations.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Develop and submit a revised digital deteriorating-patient pathway for testing, including automatic GCS access and mandatory completion where indicated.
Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Update the Vital Signs Policy to require escalation for neurological deterioration and fifteen-minute then thirty-minute observations during Naloxone infusions.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Embed revised neurological deterioration and escalation standards within ALERT and accredited Immediate Life Support training programmes.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Present revised neurological assessment and escalation standards at Urgent, Emergency, and Acute Medicine governance meetings.
Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2026.
Essex
Concerns raised1
Failure to complete required neurological observations after sustained head injury
This report raised 8 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Provide mandatory neurological-observation training to substantive, bank and non-registered staff using case studies and scenarios.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Use clinical guidance and neurological observation charts to specify post-fall neurological assessment, Glasgow Coma Scale recording and observation frequencies.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Mid Kent and Medway
Concerns raised2
Failure to document the reason for discontinuing neurological observations
Failure to continue neurological observations following head injury
Responses linked to these concerns
Each statement is shown once, even when linked to more than one 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.8
Action
Maintain a NICE-compliant Falls Policy specifying neurological-observation frequency and continuation until medical review.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Monitor compliance with neurological-observation standards through the Falls Care Pathway, incident reporting and quality governance reviews.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Include clinically indicated neurological observations in shift handovers and patient status boards, with ongoing quality assurance audits.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Use electronic NEWS2 observations to identify consciousness changes, trigger neurological observations when indicated, issue missed-observation alerts and support remote clinical review.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Train staff in electronic observations and neurological-observation competencies, with ongoing training for newly appointed nursing and medical staff.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Employ a specialist Physical Health Nurse on each ward to teach, support and supervise physical healthcare.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Deliver Trust-wide train-the-trainer education on neurological observations and the Glasgow Coma Scale to physical health nurses, with refresher sessions and online access.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Action
Develop and disseminate a learning bulletin reminding staff to complete Glasgow Coma Scale observations after incidents, possible strokes, head injuries and medical emergencies.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2021.
Black Country
Concerns raised1
Failure to provide and adjust neurological observations after head injury
This report raised 12 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.
Bedfordshire and Luton
Concerns raised1
Failure to maintain neurological observation after prolonged seizure
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.
South Wales Central
Concerns raised1
Failure to plan and maintain required continued observations
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.
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.2
Action
Use a new neuro-observation chart and restrict neuro-observation performance to registered nurses under UHB policy.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Pursue appropriate regulatory concerns concerning the nurses through fitness-to-practise procedures.
Stated by Nursing and Midwifery CouncilStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
Nottinghamshire
Concerns raised1
Failure to record Glasgow Coma Scale observations after deterioration in consciousness
This report raised 10 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 June 2018.
Inner North London
Concerns raised1
Failure to obtain and repeat immediate neurological observations after head injury
This report raised 6 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Roll out new post-head-injury guidance and training across Royal London Hospital Older Peoples Service wards.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2018.
Action
Extend the post-head-injury guidance and training rollout to other inpatient areas.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
Action
Introduce a formal trust-wide policy for managing head injury in patients and staff.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2018.
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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.
