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.
Surrey
Concerns raised1
Failure to undertake regular Paediatric Early Warning Score assessments
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.4
Action
Maintain clear, individualised, regularly updated care plans aligned with Paediatric Early Warning Scores and audit their implementation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Conduct overnight monitoring-practice audits and monthly quality walks to verify compliance with observation policies and care plans.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Action
Request monthly updates on monitoring-frequency and Paediatric Early Warning System audits to assess ongoing implementation and identify practice gaps.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 14 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Some concerns about Mia’s care are better addressed by Tadworth Children’s Trust and the Care Quality Commission.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised3
Incorrect calculation of NEWS scores
Failure to perform observations in line with NEWS requirements
Failure to refer patients to a senior medical practitioner in line with the NEWS algorithm
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 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
Meet with the digital team to define the requirement and prioritise introducing electronic observations in the Emergency Department.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 21 August 2024.
Action
Map Emergency Department processes and requirements to support electronic observation implementation.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 21 August 2024.
Action
Develop an options appraisal identifying the safest, quickest and most cost-effective approach to electronic observations, including licensing and integration costs.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2024.
Action
Obtain supplier quotations and prepare a capital bid while seeking funding prioritisation for the electronic observation project.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 21 August 2024.
Action
Introduce an electronic observation and NEWS recording system in the Emergency Department.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 21 August 2024.
Surrey
Concerns raised1
Incomplete recording of Early Warning Scores (NEWS2 Scores)
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.4
Action
Review and update policies and guidance for recognising, escalating, and managing deteriorating patients and sepsis.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024.
Action
Support and oversee clinical training on observations, NEWS2 scoring, escalation, and abnormal blood-result recognition including CRP.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024.
Action
Review and strengthen electronic-record sepsis and NEWS2 escalation tools and alerts.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024.
Action
Monitor deterioration-recognition and escalation quality-improvement projects, including senior review, critical-care referral, and abnormal-result escalation.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 August 2024.
Nottinghamshire
Concerns raised1
PEWS escalation pathway failing to trigger senior Emergency Department doctor review for scores of 6-8
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
Install live Nervecentre oversight screens to identify elevated or overdue paediatric observations and support senior monitoring.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Review and circulate the Children and Young People escalation tool, specifying escalation triggers and required actions.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Implement and disseminate senior review and out-of-hours consultant call criteria for paediatric Emergency Department care.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Require PEWS scores of 6–8 or a single parameter score of 3 to trigger review by a Tier 3 or above doctor, and cascade the guidance to staff.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Nottinghamshire
Concerns raised3
Unclear requirements for action according to the early warning score
Unclear requirements for the frequency of vital-sign observations
Unclear requirements for recording vital-sign values
This report raised 9 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
Deliver NEWS2 training to all frontline clinical staff required to undertake the assessment.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Provide NEWS2 at-a-glance ward posters and lanyard guidance attachments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Provide clinical supervision through senior Quality Matrons to support NEWS2 practice and continuous learning.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Introduce scenario-based NEWS2 examples during clinical supervision to assess staff competency around escalation.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
East London
Concerns raised1
Lack of readily accessible NEWS charts and scores during ward rounds
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
Increase laptop and iPad availability, verify Cerner compatibility and functionality, and provide computers on wheels for NEWS access.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing access arrangements are considered sufficient to enable doctors to review NEWS data in each clinical area.
Stated by Barts Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised1
Failure to escalate, assess and investigate NEWS-triggered deterioration
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.5
Action
Maintain and improve escalation protocols for recognising and responding to deteriorating patients.
Stated by Mid Yorkshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Provide ongoing deterioration-response education to nursing, allied health and junior medical staff.
Stated by Mid Yorkshire Teaching NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2023.
Action
Provide a 24/7 Deteriorating Adult Response Team for patients meeting deterioration referral criteria.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Augment the deteriorating-patient response service with additional capacity.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Action
Operate the Call 4 Concern patient-safety initiative, connecting ward calls from patients or families to Deteriorating Adult Response Team members.
Stated by Mid Yorkshire Teaching NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Points 1 and 4 of the concerns are not directly relevant to the RCR’s remit or responsibilities.
Stated by Royal College of RadiologistsOutside remitThe respondent said that this matter was outside its role or authority.
Norfolk
Concerns raised1
Failure to communicate NEWS2 scores to the 111 call taker
This report raised 7 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.
East London
Concerns raised1
Failure to promptly escalate care to a high dependency unit despite a NEWS score of 8
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire Eastern
Concerns raised1
Failure to accurately perform and interpret clinical observations for escalation
This report raised 14 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
Provide NEWS refresher training to relevant colleagues and conduct regular audits of NEWS compliance.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Deliver training to RMOs on recognising deteriorating patients and signs of gastric perforation.
Stated by Spire Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
Action
Provide deteriorating-patient training to agency staff through the supplier competency process.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Introduce deteriorating-patient stickers for clinical use.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Display NEWS 2 posters for staff reference.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
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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.
