Recurring concern
Failure to carry out required neurological observations
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Request correctionFirst reported 28 Feb 2014•Latest report 12 Jun 2026
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
- Individual concerns
- 33
- Date range
- 2014–2026
- Stated actions
- 55
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Failure to record neurological observations correctly and at the minimum recommended frequency
Use of an out-of-date post-falls checklist lacking required neurological observation details
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 concernsEach 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
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Action
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.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Deliver neurological-observation training to registered nurses and reduced-consciousness assessment training to non-registered support staff.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
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.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The recommended safety actions are primarily the responsibility of the hospital trust.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Position
The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Concerns raised1
Failure to perform neurological observations after significant hyperglycaemia
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to perform neurological observations before discharge
Failure to record post-fall neurological observations
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 concernsEach 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
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Action
Provide nurses with neurological-observation training through the Critical Care Outreach Team.
Stated by Barts Health NHS Trust -
Action
Audit nurses’ falls-policy understanding, care-plan documentation, neurological-observation understanding, and competence in performing neurological observations.
Stated by Barts Health NHS Trust -
Action
Include documentation and falls management in induction for new medical trainees.
Stated by Barts Health NHS Trust
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Action
Hold twice-daily safety briefings highlighting the Trust falls protocol.
Stated by Barts Health NHS Trust -
Action
Remind nursing staff that the nurse in charge is responsible for following and documenting the correct falls procedure.
Stated by Barts Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Appropriate neurological observations were carried out after the fall; the missing chart was inadvertently misfiled.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to make neurological observations after falls and facial injury
Responses linked to these concernsEach 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
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Action
Implement compliance with neurological investigations following head injury.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to carry out directed neurological and physical observations after 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to undertake neurological observations and further examination after a fall
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 concernsEach 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
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Action
Review policies and procedures for managing residents after unwitnessed falls.
Stated by Elizabeth Finn Homes Limited -
Action
Cascade the unwitnessed-fall procedure and require neurological observations using the Glasgow Coma Scale, recorded in residents’ care plans.
Stated by Elizabeth Finn Homes Limited -
Action
Reinforce fall-response procedures through staff meetings, monitor individual training needs, and review head-injury-care competencies.
Stated by Elizabeth Finn Homes Limited
Data last updated 7 September 2026