Recurring concern

Unreliable clinical Early Warning Score systems for deterioration

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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
Individual concerns: 94
Date range: 2013–2026
Stated actions: 138

Reports 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.

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

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.

5 Sep2014
Milton Keynes
Concerns raised3
1. Failure to ensure qualified checking and interpretation of Early Warning Observation Chart observations
2. Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care
3. Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
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.
AI-generated summary

Peter John White · 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

Peter John White was involved in a road traffic collision on 2 April 2013 and was taken to Milton Keynes Hospital with serious chest injuries. He became unwell and collapsed while undergoing a CT scan, and died on 3 April 2013 from haemothorax. Concerns included incorrect completion and inadequate checking of the Early Warning Observation Chart, ignored triggers, failures to escalate care, and the absence of a regular audit system.

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 ensure qualified checking and interpretation of Early Warning Observation Chart observations
Wider context from the report
“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”
Source location
Peter John White · Prevention of Future Deaths report
Page 1 · 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 act on Early Warning Observation Chart trigger scores through appropriate escalation of care
Wider context from the report
“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”
Source location
Peter John White · Prevention of Future Deaths report
Page 1 · 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
Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
Wider context from the report
“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”
Source location
Peter John White · Prevention of Future Deaths report
Page 1 · concerns
Open source report
11 Jul2014
Surrey
Concerns raised1
1. Failure to act on or escalate elevated Early Warning Scores
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Maria De Oliveria Alva LOPES · 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

Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.

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 or escalate elevated Early Warning Scores
Wider context from the report
“9. Failure to act on or escalate elevated Early Warning Scores as per hospital protocol ”
Source location
Maria De Oliveria Alva LOPES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Jun2014
West Sussex
Concerns raised1
1. Failure to apply or appropriately depart from the NEWS system
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 9
1. Action
  Deliver ward-based NEWS update and drop-in sessions.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
2. Action
  Review and highlight NEWS escalation issues through monthly Sisters’ meetings.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
3. Action
  Reinforce NEWS scoring and escalation during annual resuscitation training updates.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
1. Action
  Maintain and improve NEWS content in AIMS and ALERT training programmes.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
2. Action
  Document NEWS discussions and assess whether the NEWS chart requires revision.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
3. Action
  Review cardiac-arrest cases and provide feedback on inappropriate observation frequency through root-cause analysis.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
4. Action
  Provide laminated ward escalation sheets showing escalation thresholds and observation-recording requirements.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
5. Action
  Keep ward nursing-station computers available for high-flag screening and observation scheduling.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
6. Action
  Roll out outreach-team review of ward PatientTrack data across both sites and feed findings back to ward sisters.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
AI-generated summary

Denise PRIOR · 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

Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.

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 apply or appropriately depart from the NEWS system
Wider context from the report
“That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure from the ‘NEWS’ system. ”
Source location
Denise PRIOR · 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
Deliver ward-based NEWS update and drop-in sessions.

Verbatim wording from the response
“Action taken Matron’s outreach to do update sessions on the wards to ensure all know the process, using Patient Safety paper version of ward meetings, ‘drop in’ update sessions.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 2 · response
Published 2 June 2014
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 highlight NEWS escalation issues through monthly Sisters’ meetings.

Verbatim wording from the response
“Monthly agenda item at Sisters’ meetings to discuss and highlight sites to review the NEWS process; both sites to highlight low escalation.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 2 · response
Published 2 June 2014
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
Reinforce NEWS scoring and escalation during annual resuscitation training updates.

Verbatim wording from the response
“NEWS is discussed at resuscitation training annual updates – ensure that scoring and escalation is reinforced at these sessions on both sites.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 2 · response
Published 2 June 2014
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
Maintain and improve NEWS content in AIMS and ALERT training programmes.

Verbatim wording from the response
“Continue to ensure NEWS section on AIMS and ALERT course programme is adequate.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 2 · response
Published 2 June 2014
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
Document NEWS discussions and assess whether the NEWS chart requires revision.

Verbatim wording from the response
“Action taken Document what has been discussed with NEWS and whether creating NEWS chart needs revising to allow better revising to allow better documentation on chart itself.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 3 · response
Published 2 June 2014
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 cardiac-arrest cases and provide feedback on inappropriate observation frequency through root-cause analysis.

Verbatim wording from the response
“Cardiac arrest cases – all are currently reviewed, including frequency of observations. This will be fed back to teams if not appropriate as part of RCA.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 3 · response
Published 2 June 2014
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
Provide laminated ward escalation sheets showing escalation thresholds and observation-recording requirements.

Verbatim wording from the response
“Ensure all wards have:”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 3 · response
Published 2 June 2014
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
Keep ward nursing-station computers available for high-flag screening and observation scheduling.

Verbatim wording from the response
“Ensure all wards have:”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 3 · response
Published 2 June 2014
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
Roll out outreach-team review of ward PatientTrack data across both sites and feed findings back to ward sisters.

Verbatim wording from the response
“Patient track data reporting – We are planning to roll out the wound care team of the outreach team onto both sites – reviewing individual ward data and feeding back to the sisters. This looks at timeliness of observations in relation to NEWS scores in escalation process. This will highlight wards who may need extra support and more education.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 7 · response
Published 2 June 2014
Open published response
15 May2014
Manchester South
Concerns raised1
1. Subjective interpretation of Early Warning Scores
This report raised 11 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 2
1. Action
  Roll out Patientrack phase one across wards for electronic vital-sign input.
  Stated by Stockport NHS Foundation TrustStated in progress
2. Action
  Introduce Patientrack alert functionality in the planned second rollout phase.
  Stated by Stockport NHS Foundation TrustStated planned
AI-generated summary

Gary Bradshaw · 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

Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

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
Subjective interpretation of Early Warning Scores
Wider context from the report
“12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the ‘manual’ assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores. (Stockport NHS Trust and The Secretary of State) ”
Source location
Gary Bradshaw · 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
Roll out Patientrack phase one across wards for electronic vital-sign input.

Verbatim wording from the response
“12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the manual assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores. “Patientrack” is the electronic track and trigger system purchased by the Trust and this system generates an urgent alert to Doctors and other clinicians of potentially deteriorating patients. This system has been piloted and evaluated on one ward in the Trust and is due to be rolled out across the Trust. Phase one of the rollout, which will focus on the input of vital signs only, has commenced and is being introduced on a ward by ward basis, with the alert functionality activated in phase two, planned to commence in January 2015.”

Source location
2014-0232-Response-2
Page 4 · response
Published 15 May 2014
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 Patientrack alert functionality in the planned second rollout phase.

Verbatim wording from the response
“12. There seemed to have been a very subjective interpretation of the EWS at the hospital by using the manual assessment method. I was told that an electronic version is being rolled out. I would hope that this can be sooner rather than later as it will give a far better and more objective assessment of the Early Warning Scores. “Patientrack” is the electronic track and trigger system purchased by the Trust and this system generates an urgent alert to Doctors and other clinicians of potentially deteriorating patients. This system has been piloted and evaluated on one ward in the Trust and is due to be rolled out across the Trust. Phase one of the rollout, which will focus on the input of vital signs only, has commenced and is being introduced on a ward by ward basis, with the alert functionality activated in phase two, planned to commence in January 2015.”

Source location
2014-0232-Response-2
Page 4 · response
Published 15 May 2014
Open published response
26 Feb2014
Brighton and Hove
Concerns raised1
1. Failure to act on NEWS scores
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Herta Edith Maria WOODS · 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

Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

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 NEWS scores
Wider context from the report
“(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment. ”
Source location
Herta Edith Maria WOODS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
27 Nov2013
Berkshire
Concerns raised1
1. Failure to calculate EDD scores accurately and trigger required Doctor review
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 3
1. Action
  Implement policy requiring independent verification of deteriorating-adult EDOD score calculations.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Audit compliance with accurate EDOD score calculation and appropriate algorithm use.
  Stated by Frimley Health NHS Foundation TrustStated completed
3. Action
  Introduce electronic MSS calculation of EDOD scores in the Emergency Department.
  Stated by Frimley Health NHS Foundation TrustStated completed
AI-generated summary

Edna Elsie Mary Eden · 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

Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

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 calculate EDD scores accurately and trigger required Doctor review
Wider context from the report
“(2) The nursing observation chart suggested infrequent observations for a patient who had not yet been clerked by a Doctor. The EDD score was wrongly calculated which meant an escalation of Doctor review was not carried out. ”
Source location
Edna Elsie Mary Eden · 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
Implement policy requiring independent verification of deteriorating-adult EDOD score calculations.

Verbatim wording from the response
“However, in addition I wanted to specifically point out that a new Policy i.e. TPP 231 (enclosed) which focuses on the Management of the Deteriorating Adult Patient was introduced in August 2013. This Policy has introduced a new requirement for ensuring that the EDOD score calculation is verified by another member of staff to reduce inaccuracies as was in this case. An audit capturing the number of correctly calculated EDOD scores was carried out in July 2013 and the results of this audit highlighted very good compliance; with all standards exceeding the 90% mark and as well as showing that every patient with an increased EDOD score had the algorithm followed appropriately.”

Source location
2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
Page 1 · response
Published 22 February 2014
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
Audit compliance with accurate EDOD score calculation and appropriate algorithm use.

Verbatim wording from the response
“However, in addition I wanted to specifically point out that a new Policy i.e. TPP 231 (enclosed) which focuses on the Management of the Deteriorating Adult Patient was introduced in August 2013. This Policy has introduced a new requirement for ensuring that the EDOD score calculation is verified by another member of staff to reduce inaccuracies as was in this case. An audit capturing the number of correctly calculated EDOD scores was carried out in July 2013 and the results of this audit highlighted very good compliance; with all standards exceeding the 90% mark and as well as showing that every patient with an increased EDOD score had the algorithm followed appropriately.”

Source location
2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
Page 1 · response
Published 22 February 2014
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 electronic MSS calculation of EDOD scores in the Emergency Department.

Verbatim wording from the response
“The new MSS system was introduced in the Emergency Department on 14 January 2014 and has an added function of calculating the EDOD score electronically thereby reducing the possibility of wrong calculations.”

Source location
2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
Page 2 · response
Published 22 February 2014
Open published response
24 Sep2013
South Yorkshire (Western)
Concerns raised4
1. Failure to contact a consultant when Early Warning Scores indicate clinical deterioration
2. Failure to refer patients to consultant level when Early Warning Scores indicate escalation
3. Failure to calculate Early Warning Scores accurately
1. Lack of a single standardised Early Warning Score calculation system
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.
AI-generated summary

Jude Augustus Gordon · 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

Jude Augustus Gordon underwent surgery and anaesthesia on 23 November 2011, deteriorated with signs of respiratory failure on 27 November, and died shortly after suffering a cardiac arrest. The concerns included failure to escalate his treatment or refer him to critical care, miscalculation of the Early Warning Score, variation in how scores were calculated between Trusts, and the absence of an automatic alert system for senior clinicians.

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 contact a consultant when Early Warning Scores indicate clinical deterioration
Wider context from the report
“(2) Evidence was given at the inquest, by a consultant, that if he had been called to see Mr Gordon at the time his condition deteriorated, as was indicated by the Early Warning Score system should have happened, then he would have referred to critical care. He was not contacted. I was informed at the inquest that a Trust in Birmingham has a computerised system, that leads to an automatic alert to the relevant senior doctor on each occasion that a Early Warning Score exceeds the relevant level, for contact to be required. Such a system would on the 27th November 2011, to the consultant attending on Mr Gordon. ”
Source location
Jude Augustus Gordon · 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 refer patients to consultant level when Early Warning Scores indicate escalation
Wider context from the report
“(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system. ”
Source location
Jude Augustus Gordon · 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 calculate Early Warning Scores accurately
Wider context from the report
“(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system. ”
Source location
Jude Augustus Gordon · 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
Lack of a single standardised Early Warning Score calculation system
Wider context from the report
“(1) As stated the Early Warning Score in Sheffield is referred to as SHEWS. It was clear from the evidence that for a period of almost four and a half hours, prior to his final collapse, Mr Gordon’s score had shown a marked increase. This in itself should have led to referral to consultant level which did not happen. It was also apparent that there had been a miscalculation of the Early Warning Score, by more than one individual. The court was informed, by expert evidence, that there are differences in the method of calculating an Early Warning Score, between different Trusts. Nursing staff, but in particular junior doctors, who are often the person to make the decision to increase the level of treatment, have either trained or worked in different Trusts. This may lead to confusion. It was not clear to me why there is not a single, National, Early Warning Score system. ”
Source location
Jude Augustus Gordon · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised3

Failure to ensure qualified checking and interpretation of Early Warning Observation Chart observations

Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care

Lack of regular audit of Early Warning Observation Chart completion, interpretation and action

Concerns raised1

Failure to act on or escalate elevated Early Warning Scores

Concerns raised1

Failure to apply or appropriately depart from the NEWS system

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

Concerns raised1

Subjective interpretation of Early Warning Scores

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

Concerns raised1

Failure to act on NEWS scores

Concerns raised1

Failure to calculate EDD scores accurately and trigger required Doctor review

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

Concerns raised4

Failure to contact a consultant when Early Warning Scores indicate clinical deterioration

Failure to refer patients to consultant level when Early Warning Scores indicate escalation

Failure to calculate Early Warning Scores accurately

Lack of a single standardised Early Warning Score calculation system

Actions described in response 9

Actions described in response 2

Actions described in response 3