Recurring concern

Unreliable recording and follow-up of clinical escalations

First to latest report 4 Apr 2024 — 20 Jan 2026

Reports that mention this concern: 2
Times this concern has been raised: 3
Stated actions linked to this concern: 4

What this concern includes

Includes failures in recording, completing, communicating, assigning or tracking clinical escalations and their resulting actions, including Nerve Centre escalation records and escalation-related handovers where the deficiency can leave follow-up unclear or incomplete.

What is not included

Excludes generic clinical-record, handover or documentation failures where no clinical escalation or resulting action is involved.
Excludes failures in the clinical assessment or decision that prompted an escalation when the escalation-record and follow-up process itself is not deficient.
Excludes failures to implement actions after they have been clearly recorded, assigned and tracked through a reliable escalation process.
Excludes non-clinical operational escalations and generic incident-reporting processes unrelated to patient-care escalations.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Doncaster Royal Infirmary1

Sherwood Forest Hospitals NHS Foundation Trust1

Reports and published responses 2 reports

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

20 Jan2026
South Yorkshire (Eastern)
Concerns raised2
1. Failure to follow up Nerve Centre system escalation triggers
2. Failure to properly complete Nerve Centre system escalation records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Stated actions 1
1. Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
  Reinforce Nerve Centre escalation procedures so triggers are actioned, followed up and fully documented, including the receiving clinician’s name and role.
AI-generated summary

Dennis Keith Price · 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

Dennis Keith Price, a 71-year-old man, died on 28 October 2024 after falling while making his way unescorted to the toilet during a hospital admission. He suffered a subdural haemorrhage after the fall, and concerns included incomplete post-fall review, unclear neurological-observation instructions, and delays or failures in responding to Nerve Centre alerts.

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 follow up Nerve Centre system escalation triggers
Wider context from the report
“3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective. ”
Source location
Dennis Keith Price · 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 properly complete Nerve Centre system escalation records
Wider context from the report
“3. The efficiency of the Nerve Centre system escalations in that any triggers must be followed up and properly completed on the system for the nerve centre system to be fully effective. ”
Source location
Dennis Keith Price · 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
Reinforce Nerve Centre escalation procedures so triggers are actioned, followed up and fully documented, including the receiving clinician’s name and role.

Verbatim wording from the response
“The Trust recognises the importance of the Nerve Centre system in supporting timely escalation and clinical decision-making and acknowledges the concern raised regarding the effectiveness of escalations where system triggers are not fully completed. Review of Mr Price’s care identified a documentation gap within Nerve Centre, specifically the absence of a recorded name confirming to whom the escalation was made, which limited assurance that the escalation process had been completed as intended. For the Nerve Centre system to function effectively, it is essential that all triggers are acted upon, followed up and fully documented, including clear identification of the clinician to whom concerns are escalated.”

Source location
2026-0037 - Response from Doncaster Royal Infirmary
Page 2 · response
Published 26 January 2026
Open published response
4 Apr2024
Nottinghamshire
Concerns raised1
1. Failure to produce clear action plans and allocated tasks from handovers and escalations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Sherwood Forest Hospitals NHS Foundation Trust
Stated actions 3
1. Sherwood Forest Hospitals NHS Foundation Trust
  Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.
2. Sherwood Forest Hospitals NHS Foundation Trust
  Use designated Tier 3-or-above doctors to oversee children’s care, reducing handovers and improving continuity.
3. Sherwood Forest Hospitals NHS Foundation Trust
  Review and circulate the Children and Young People escalation tool, including triage-time triggers and required escalation actions.
AI-generated summary

Tommy Jay Gillman · 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

Tommy Jay Gillman died on 8 December 2022 at Leicester Royal Infirmary after Salmonella Brandenberg meningitis caused sepsis and multi-organ failure. The report identified missed opportunities at Kings Mill Hospital, including delays in triage, escalation, monitoring, intravenous fluids and antibiotics. Concerns included insufficient paediatric nursing cover, undocumented handovers and an inadequate system for recognising and escalating the care of seriously ill babies.

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 produce clear action plans and allocated tasks from handovers and escalations
Wider context from the report
“2. Handovers and key conversations between staff, both nursing and medical staff, in ED and with Paediatric staff are not routinely documented, and outcomes from handovers and escalations do not result in clear action plans and allocated tasks ”
Source location
Tommy Jay Gillman · 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
Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.

Verbatim wording from the response
“SBAR (Situation, Background, Assessment and Recommendation) is the recognised structure for communication and handing over patients for staff. The ED Registered Nurse local induction covers structured handovers and accountability handover and staff are provided with examples of how to use handover effectively. Whilst structured handovers must be used for any verbal handover there was no documentation requirement to confirm whether this had taken place at the time of Tommy’s attendance to the ED. The ED Paediatric triage document has been updated and nurses are now required to confirm an SBAR verbal handover has been provided:”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 15 April 2024
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
Use designated Tier 3-or-above doctors to oversee children’s care, reducing handovers and improving continuity.

Verbatim wording from the response
“SBAR is also a recognised structure for medical handover and all Sherwood Forest clinical staff are required to utilise a structured handover to ensure effective and assertive communication. In addition, use of a structured handover ensures clear recommendations are provided, preventing ambiguity through encouraging clinical staff to repeat the information back to the provider to confirm understanding and allocation of tasks. In addition, changes to the medical model and provision of a designated Tier 3 (previously referred to as a Registrar or Middle Grade) or above Doctor to oversee the care of all children reduces the number of handovers required and improves the continuity of care.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 3 · response
Published 15 April 2024
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
Review and circulate the Children and Young People escalation tool, including triage-time triggers and required escalation actions.

Verbatim wording from the response
“Children and young people escalation tool.”

Source location
Response from Sherwood Forest Hospitals NHS Foundation Trust
Page 5 · response
Published 15 April 2024
Open published response