Recurring concern

Unreliable clinical Early Warning Score systems for deterioration

First to latest report 24 Sep 2013 — 5 Feb 2026

Reports that mention this concern
67
Times this concern has been raised
94
Stated actions linked to this concern
138

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.

What is 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 and published responses 67 reports

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

  1. Manchester West

    AI-generated summary

    Margaret Mary Gleeson · 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

    Margaret Mary Gleeson underwent elective incisional hernia repair and sustained a tear to her mesentery, after which her condition deteriorated and she developed sepsis. She suffered a cardiac arrest during further surgery and died on 4 October 2015; concerns included weekend staffing levels and inaccurate or poorly understood use of the MEWS tool.

    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 accurately score MEWS tools on medical charts

    Wider context from the report

    “2. The scoring of the MEWS tool on the medical charts had been done inaccurately, and the use of the MEWS tools did not appear to be clearly understood. It would appear that refresher training would assist ”

    Source location

    Margaret Mary Gleeson · 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 extensive staff training on accurate MEWS and fluid-balance recording and recognition and response to patient deterioration, including sepsis.

    Verbatim wording from the response

    “Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Continue monthly deterioration, MEWS and fluid-balance training for staff involved in patient care.

    Verbatim wording from the response

    “Since the conclusion of the inquest in June 2016 the Trust has provided extensive training programmes both in the accuracy and recording of MEWS and fluid balance, but also in recognising and responding appropriately to the early signs of deterioration in patients, including sepsis. The enclosed Action Plan provides extensive evidence of the training sessions held to date, and those sessions will continue on a monthly basis for all Trust staff involved in patient care.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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 the QUEST programme to train nursing staff in MEWS use and accurate scoring.

    Verbatim wording from the response

    “Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Conduct monthly audits of nursing compliance with MEWS standards and feed results back to ward and nursing managers.

    Verbatim wording from the response

    “Firstly, with regards to training of the MEWS tool this has been led by the Trust’s Critical Care Outreach Lead, ████████, through the QUEST programme. This programme trains nursing staff on the use of the MEWS tool, and highlights the importance of accurate scoring. A dedicated Critical Care Outreach Nurse also undertakes monthly audits of compliance with MEWS standards. Copies of these audits are embedded within the enclosed Action Plan and the results are fed back to Ward Managers and Heads of Nursing for action to be taken, wherever necessary. They are also monitored through the Trust’s Harm Free Care Board.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    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

    Operate a monthly Task and Finish Group to oversee MEWS use, audit findings, compliance and scoring accuracy.

    Verbatim wording from the response

    “In addition to this, the Trust’s Director of Nursing, ████████, has established since the inquest, and is currently chair of, a dedicated Task and Finish Group to oversee the use of the MEWS Tool. The Group meets on a monthly basis to discuss the audit findings and to monitor compliance and accuracy of scoring.”

    Source location

    2016-0255-Response-by-Wrighton-Wigan-and-Leigh-NHS-Trust
    Page 2 · response
    Published 15 July 2016

    Open published response

  2. Manchester North

    AI-generated summary

    baby Dominic Smith · 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

    Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.

    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 act on early warning scores

    Wider context from the report

    “Pennine Acute Hospitals NHS Trust: 1. During the course of the inquest into Baby Smith’s death, the following concerns arose: - Inadequate communication, handover and record keeping; - Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion; - Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this; - Early warning scores were i) miscalculated, ii) not acted upon; - Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed; - Maternal observations were not carried out after delivery, despite a spike in temperature; - Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist & - Inadequate preceptorship for newly qualified (and particularly part-time) Midwives. ”

    Source location

    baby Dominic Smith · 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

    Miscalculation of early warning scores

    Wider context from the report

    “Pennine Acute Hospitals NHS Trust: 1. During the course of the inquest into Baby Smith’s death, the following concerns arose: - Inadequate communication, handover and record keeping; - Staff did not follow the Trust’s protocols/guidance and did not document their rationale where they exercised clinical discretion; - Midwives did not carry out a speculum examination, on two separate occasions, in order to establish whether there had been a rupture of membranes. The time between rupture and delivery was, more likely than not, miscalculated as a result of this; - Early warning scores were i) miscalculated, ii) not acted upon; - Neonatal observations were not carried out when it became apparent that there had been a material change in baby’s condition. Signs and symptoms relating to the deterioration were also missed; - Maternal observations were not carried out after delivery, despite a spike in temperature; - Midwives did not escalate to or consult with the Obstetrician/Paediatrician/Neonatologist & - Inadequate preceptorship for newly qualified (and particularly part-time) Midwives. ”

    Source location

    baby Dominic Smith · 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 Critical Care outreach support and follow-up when elevated early warning scores are identified.

    Verbatim wording from the response

    “The Critical Care outreach team are also supporting the Division where elevated early warning scores are identified. This involves direct care by the outreach team and subsequent follow up to ensure stabilisation of the patient.”

    Source location

    2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
    Page 3 · response
    Published 30 June 2016

    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 the Trust-wide project and improvement measures to improve accurate acute monitoring using early warning scores.

    Verbatim wording from the response

    “Undertaking correct acute monitoring of patients condition, through using early warning score is currently a Trust wide project to improve practice.”

    Source location

    2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
    Page 2 · response
    Published 30 June 2016

    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

    Pilot the revised Maternity Early Warning Scoring Chart and make necessary alterations before embedding it in practice.

    Verbatim wording from the response

    “Within the maternity services, a specific Maternity Early Warning Scoring Chart (MEWS) has been revised which has greater sensitivity to the needs of the physical parameters of women during pregnancy. This tool is in the pilot phase currently to enable any necessary alterations to be implemented prior to being fully embedded in practice.”

    Source location

    2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
    Page 2 · response
    Published 30 June 2016

    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

    Introduce a newborn observation chart based on the British Association of Paediatric Medicine Newborn Early Warning Score.

    Verbatim wording from the response

    “There has been an audit as part of the divisional yearly programme looking at compliance with the Early Onset Sepsis Guidelines. Actions put in place following the audit was to introduce a new observation chart based on the Newborn Early Warning Score recommended by British Association of Paediatric Medicine (BAPM) and this work is in progress. Once completed there will be further audits to monitor compliance.”

    Source location

    2016-0240-Response-by-The-Pennine-Acute-Hospital-NHS-Trust
    Page 3 · response
    Published 30 June 2016

    Open published response

  3. West Yorkshire (Western)

    AI-generated summary

    June Elsie Parkes · 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

    June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

    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 of nursing staff to accurately score vital signs in the NEWS system

    Wider context from the report

    “(4) Nursing staff compliance with the news system both in respect of accurately scoring each of the various vital signs, and recognising and implementing any escalation measures that are recommended . ”

    Source location

    June Elsie Parkes · Prevention of Future Deaths report
    Page 3 · 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 of nursing staff to recognise and implement recommended NEWS escalation measures

    Wider context from the report

    “(4) Nursing staff compliance with the news system both in respect of accurately scoring each of the various vital signs, and recognising and implementing any escalation measures that are recommended . ”

    Source location

    June Elsie Parkes · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Shalini GANESH-RAM · 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

    Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

    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 use the modified obstetric early warning score tool appropriately to identify sepsis

    Wider context from the report

    “4. Your own serious incident report has already identified other issues around service delivery, most particularly that the modified obstetric early warning score tool was not used appropriately to identify Ms Ganesh-Ram’s sepsis. ”

    Source location

    Shalini GANESH-RAM · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Brighton and Hove

    AI-generated summary

    Thelma Patricia 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

    Thelma Patricia JONES was admitted to the Acute Medical Unit from 16 to 23 February 2015, became acutely unwell, and was moved to intensive therapy after being intubated on the unit. The concerns were limited evidence of coordinated care planning and incomplete National Early Warning System scoring after her acute deterioration and a medical emergency team call on 23 February 2015.

    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 complete National Early Warning System scoring after acute deterioration

    Wider context from the report

    “This report once again, concerns the Acute Medical Unit (AMU) where Mrs. JONES was admitted from the 16th - 23rd February 2015 when she became acutely unwell and was moved to ITU having been intubated on AMU. • firstly the fact that there was very little evidence of any joined up thinking with regard to her care or to plans, either for her future treatment or for her future placement, or for discharge whilst in AMU and I would certainly like to have seen that. • The second matter is once again the question of the National Early Warning System (NEWS), which had been reasonably well completed until we come to the day of her acute deterioration, when after a NEWS score of 8, and a medical emergency team call made at about 09:45 on the morning of the 23rd February 2015, the scoring is not completed. This is extremely poor; it is a matter that I have raised before and it must, please, be addressed. ”

    Source location

    Thelma Patricia JONES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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

    NEWS scores were not expected during the medical emergency because the early warning system had already fulfilled its function.

    Verbatim wording from the response

    “In summary it would not be expected that NEWS scores would be calculated from the observations during a medical emergency response as the focus is on rapidly treating and managing the patient. The NEWS is an early warning system and it had fulfilled its function at the point a MET call was made.”

    Source location

    2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 12 August 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

    No remedial action was considered necessary because the medical records contained appropriate detail about AMU care and NEWS scores.

    Verbatim wording from the response

    “As with all cases we have carefully reflected on the issues in this situation and are open and committed to learning from such events. In this particular case, the Trust believes that the medical notes contain appropriate detailed information on the care and treatment given within AMU and in relation to the NEWS scores. To that end we do not believe that remedial action is necessary on the part of the Trust in this respect.”

    Source location

    2015-0318-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 12 August 2015

    Open published response

  6. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · 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

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    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 NEWS scores on drug charts

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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 escalate NEWS scores to doctors

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · 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

    Monitor documentation more closely and provide nurses with real-time feedback.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 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

    Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.

    Verbatim wording from the response

    “Extensive and complex work is also being undertaken to”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 7 May 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

    Assign a critical care outreach nurse to link the Acute Medical Unit with critical care services.

    Verbatim wording from the response

    “Changes, introduced mainly before the inquest into Mrs Kennedy’s sad death as part of the ongoing programme of improvements, include:”

    Source location

    2015-0178-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 7 May 2015

    Open published response

  7. Inner North London

    AI-generated summary

    Sabrina Stevenson · 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

    Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

    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 progress a pre-hospital validated early warning score system

    Wider context from the report

    “(5) The potential for an ‘early warning score’ system, which is specifically validated for pre-hospital use, was welcomed by LAS but without further evidence as to how this might be taken forward by the Trust, in collaboration with other agencies. Further steps in this regard are required in my view; ”

    Source location

    Sabrina Stevenson · Prevention of Future Deaths report
    Page 3 · 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 the possibility of introducing a pre-hospital early warning score system in London.

    Verbatim wording from the response

    “As with the introduction of pregnancy testing the Medical Director sought the views of National Ambulance Service Medical Directors’ Group (NASMeD) at their meeting on 21 April 2015 on the use of a national early warning score (NEWS) system in the pre-hospital environment to inform our assessment of the feasibility of introducing an early warning score”

    Source location

    2015-0126-Response-by-London-Ambulance-Service
    Page 5 · response
    Published 30 March 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

    Raise a national pre-hospital early warning system with JRCALC and request its inclusion in the scheduled workstream agenda.

    Verbatim wording from the response

    “1. As a member of the JRCALC, the College of Paramedics will raise the issue of a national early warning system with the JRCALC and propose that this work is scheduled into the JRCALC workstream. We will write to the Chair of the JRCALC before 5 June 2015 requesting that this item is included on the agenda for its meeting scheduled for 25 June 2015”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 3 · response
    Published 30 March 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

    Participate in national working groups or committees developing and establishing an early warning system compatible with receiving health facilities.

    Verbatim wording from the response

    “2. The College of Paramedics will participate on any working groups or committees that might be convened at a national level to develop and establish an effective national early warning system that can be applied in pre-hospital care and which would be compatible with receiving health facilities.”

    Source location

    2015-0126-Response-by-College-of-Paramedics
    Page 3 · response
    Published 30 March 2015

    Open published response

  8. Nottinghamshire

    AI-generated summary

    Philip Robinson · 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

    Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.

    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 reliably record and communicate the Early Warning Score across healthcare staff

    Wider context from the report

    “The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital ”

    Source location

    Philip Robinson · 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

    Unclear interim arrangements for where the Early Warning Score is recorded

    Wider context from the report

    “The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded. ”

    Source location

    Philip Robinson · 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

    Unavailability of the iHospital system for improving Early Warning Score recording

    Wider context from the report

    “The iHospital which undoubtedly will assist in improving EWS recording, is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded. ”

    Source location

    Philip Robinson · 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

    Embed ward safety briefings and provide education to improve multidisciplinary communication of EWS.

    Verbatim wording from the response

    “• The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The safety brief at the end of the ward round involves the whole of the ward team including HCA’s to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit. Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 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

    Embed a status-at-a-glance board showing EWS scores and due observation times on ATC.

    Verbatim wording from the response

    “• The i-Hospital is not yet in place. Implementation is planned for June 2015, and there is potential for delay. Interim plans for a ‘At a glance Board’ are not clear, with confusion as to where the EWS will be recorded. The “status at a glance” board is now embedded in practice on ATC. The board shows the EWS Score and the next time observations are due to be performed. The i-Hospital program is progressing well and plans remain optimistic that it will be in place by late summer 2015.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 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

    Implement the i-Hospital system to identify high EWS patients, due observations and discharge EWS assessment opportunities.

    Verbatim wording from the response

    “The i-Hospital white board system is due for implementation later this year. This will highlight which patients have a high EWS and the next due time of observations. On discharging a patient from the system, the system will provide the nurse with an additional opportunity to assess EWS on discharge.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 2015

    Open published response

  9. Manchester South

    AI-generated summary

    Elsie Mallalie u · 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

    Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.

    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 accurately calculate and use patient observation scores

    Wider context from the report

    “4. Whilst the staffing levels on ward 41 probably met the National Guidelines, it was clear that the ward was exceptionally busy both as to numbers of patients, but also as to the complexity of their conditions. There were only two qualified staff available and they simply could not cope (an example of this was that she had her observations taken at 8.30 pm approximately, and not thereafter for the whole of that night shift. A doctor attended her at approximately 2.30 am and “guessed” her observation scores or alternatively used those of several hours earlier. Her PAR score at 8.30 pm was reduced (wrongly) as 4 (it was in fact 6) and by the following morning day shift it had risen to 10) ”

    Source location

    Elsie Mallalie u · 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

    Replace PARS with NEWS, train Trust staff in NEWS scoring, provide an escalation guide and maintain refresher training as needed.

    Verbatim wording from the response

    “With regards the failure to take observations during the night shift; this occurred because a member of the nursing staff unfortunately miscalculated the PARS score, which meant that Mrs Mallalieu did not have her observations taken as she would have done if scoring had been correct. Since Mrs Mallalieu’s treatment the PARS scoring system has been replaced by a different system called NEWS and Trust staff have been trained in the use of it. A quick reference NEWS escalation and response guide has also been made available to all staff. The NEWS system is more sensitive than most other existing systems and it provides an enhanced level of surveillance and clinical review of patients with greater specificity in identifying those at risk of clinical deterioration.”

    Source location

    2014-0501-Response-by-Tameside-Hospital-NHS-Trust
    Page 3 · response
    Published 17 November 2014

    Open published response

  10. Warwickshire

    AI-generated summary

    Evelyn Mary Smith · 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

    Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.

    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

    Difficulty entering Paediatric Early Warning Scoring information into GP medical records

    Wider context from the report

    “(1) The care provided to Miss Smith was reviewed by an independent paediatrician and a General Practitioner. I heard evidence that the accurate and consistent recording of Miss Smith’s vital signs may have allowed earlier recognition of the severity of her illness. I also heard that the use of the Paediatric Early Warning Scoring system in General Practice may be a useful way of documenting this information. However, it was clear that information in this form is not easy to enter into GP medical records. (2) From the evidence heard at Miss Smith’s inquest it was apparent that the scoring system for croup severity was not widely known amongst the clinicians involved in her care. However, her GP did learn of this scoring system after reviewing the ‘clinical mentor’ tool through the practice’s computer software. I heard evidence that systems are in place to prompt entry of certain clinical parameters in specific scenarios; predominantly chronic disease review consultations, such as for diabetes and asthma etc. I am concerned that the GP computer system contains important and clinically relevant information, such as the croup severity score but does not alert the clinician to complete it. I heard that it should be possible to prompt the entry of relevant clinical parameters after a diagnostic code has been entered into a consultation record. ”

    Source location

    Evelyn Mary Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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