First reported 24 Sep 2013•Latest report 5 Feb 2026
Definition
What this concern includes
Includes failures to obtain, record or repeat required EWS observations; calculate scores accurately; make charts and scores accessible; define monitoring intervals; and initiate review or escalation required by EWS or NEWS thresholds.
Not included
Excludes physiological monitoring that is not part of an Early Warning Score system.
Excludes failures after a score has been correctly calculated, made available and escalated according to the applicable EWS protocol.
Excludes fetal CTG, condition-specific monitoring and non-clinical scoring tools.
Reports
67
Distinct published reports
Individual concerns
94
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
138
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.
Department of Health and Social Care8
NHS England8
University Hospitals Sussex NHS Foundation Trust6
Care Quality Commission4
Barts Health NHS Trust3
Cwm Taf Morgannwg University Local Health Board3
Pennine Acute Hospitals NHS Trust3
Royal College of Paediatrics and Child Health3
Aneurin Bevan University LHB2
Bedfordshire Hospitals NHS Foundation Trust2
Blackpool Teaching Hospitals NHS Foundation Trust2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust2
Mid and South Essex NHS Foundation Trust2
Royal College of Emergency Medicine2
Royal College of Obstetricians and Gynaecologists2
NHS trust42
Healthcare site11
Executive non-departmental public body9
Ministerial department8
Health professional body7
Local health board6
Health and social care service regulator4
Private limited company4
Professional body3
Registered charity2
Coronial office1
Devolved government1
English unitary authority1
Executive agency1
Health and care professional regulator1
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.
Gwent
Concerns raised1
Unsafe downgrading of NEWS scores for all patients with COPD when baseline oxygen saturations are unknown
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
Launch and standardise NEWS2, including the COPD-specific oxygen saturation scale, across the Health Board.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Train all flow centre staff to calculate NEWS2 and monitor compliance through annual staff reviews.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Escalate all COPD referrals to qualified nurses for contextual NEWS2 assessment, clinically justified parameter adjustments and documented rationale.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Using NEWS scale 2 for COPD patients at risk of hypercapnic respiratory failure is appropriate recognition, not downgrading.
Stated by Welsh Ambulance Services NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is considered necessary beyond the organisational learning already shared.
Stated by Welsh Ambulance Services NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Position
Adjusting NEWS oxygen-saturation scores can be acceptable for COPD patients with hypercapnic respiratory failure or lower baseline saturations, when clinically justified.
Stated by Aneurin Bevan University LHBDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure to use the specialist National Early Warning Score matrix for prenatal women throughout the hospital
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.9
Action
Develop the national Maternity Early Warning Score using pregnancy-specific thresholds for deterioration recognition and escalation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Develop national digital specifications supporting consistent implementation of MEWS across maternity and non-maternity electronic patient record systems.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Disseminate draft MEWS digital specifications to suppliers through the NHS Futures platform ahead of formal publication.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Publish the final MEWS digital specifications in Spring 2026.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
Action
Publish the Maternal Care Bundle setting national maternity safety standards, including MEWS implementation across relevant care settings.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Establish an operational group to coordinate a Trust-wide maternal early warning score approach.
Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Develop a Trust-wide maternal early warning score approach suitable for all applicable clinical areas.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Roll out a paper-based maternal early warning score process organisation-wide, supported by training and aligned with national guidance and local governance, by March 2027.
Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
Action
Explore developing an in-house digital solution to support maternal early warning score implementation.
Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current digital systems cannot support introducing the national Maternal Early Warning Score because they cannot be adapted to accommodate it.
Stated by University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Delay and inappropriate escalation of a high NEWS score
This report raised 18 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
Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.
Stated by the Princess Alexandra Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 November 2025.
Action
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An emergency call was not required because appropriate care was initiated promptly after the raised NEWS score.
Stated by the Princess Alexandra Hospital NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
East London
Concerns raised1
Lack of an electronic observation system for automatically escalating high NEWS scores in A&E
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.1
Action
Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 June 2025.
Inner North London
Concerns raised1
Failure to include blood pressure in the national paediatric early warning score
This report raised 5 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.4
Action
Implement the national PEWS approach in the electronic patient record by the national deadline.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Action
Use a cross-site multidisciplinary working group to oversee PEWS implementation, education, staffing, guidelines and risk evaluation.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Include blood pressure as an observation in the national paediatric early warning score.
Stated by Royal College of Paediatrics and Child HealthStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Collaborate with NHS England and the Royal College of Nursing to develop a single national PEWS for England.
Stated by Royal College of Paediatrics and Child HealthStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Although blood pressure was not recorded, it was likely normal and would not have changed Billie’s outcome.
Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
National PEWS is not currently supported for use in emergency departments; an ED-specific version is being developed and tested.
Stated by Royal College of Emergency MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure to trigger a Medical Emergency call when elevated NEWS scores require medical review
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.3
Action
Share learning from the case and reinforce NEWS2 escalation, trigger-response-team and local escalation requirements with surgical staff.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Reiterate NEWS and local clinical escalation processes to new surgical residents during standard induction.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Riding and Hull
Concerns raised1
Failure to appropriately escalate NEWS2 scores above seven for specialist advice
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.4
Action
Update and seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2025.
Action
Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
Stated by NHS Humber Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2025.
Action
Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
Stated by NHS Humber Health PartnershipStated completedThe respondent said that this action was complete when they made their response on 24 January 2025.
Action
Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to record Labour Ward vital signs on required MEOWS charts
This report raised 15 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.4
Action
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
East Riding and Hull
Concerns raised2
Inaccurate recording of Early Warning Signs
Failure to escalate Early Warning Signs
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.2
Action
Obtain and review the service’s care records to determine whether further regulatory action is needed.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2024.
Action
Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Neither inspection identified inaccurate record keeping; checks and audits were in place to support good governance.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Neither inspection raised concerns about staff failing to escalate health concerns, and the earlier inspection found appropriate healthcare referrals.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to escalate National Early Warning Scores for review
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.
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.6
Action
Require all inpatient nursing staff to complete a mandatory two-day physical health and NEWS2 training course.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Action
Include NEWS2 escalation training in the annual mandatory online programme and monitor completion.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Action
Standardise the nursing handover process across Tower Hamlets to communicate patient risks and physical-health observation requirements.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Action
Roll out the standardised nursing handover process across the Trust’s other directorates.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 November 2024.
Action
Generate a daily NEWS2 report identifying scores of three or above, review ward responses and escalation, and record the process for audit.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
Action
Introduce a Nurse in Charge training tool requiring confirmation that NEWS2 monitoring and escalation responsibilities have been understood.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2024.
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Includes failures to obtain, record or repeat required EWS observations; calculate scores accurately; make charts and scores accessible; define monitoring intervals; and initiate review or escalation required by EWS or NEWS thresholds.
