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.

13 Jun2023
East London
Concerns raised1
1. Failure to escalate monitoring in accordance with the NEWS policy
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.

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

Raquel Mellonie Harper · 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

Raquel Mellonie Harper attended Whipps Cross Hospital with shortness of breath and difficulty breathing, but a D Dimer test was not carried out and her condition later deteriorated. She suffered a cardiac arrest and died at the hospital on 25 June 2021. Concerns included inadequate history taking, failure to escalate monitoring after a high NEWS score, and disagreement or unclear wording in the Trust’s pulmonary embolism policy.

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 escalate monitoring in accordance with the NEWS policy
Wider context from the report
“2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff. ”
Source location
Raquel Mellonie Harper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Apr2022
Surrey
Concerns raised1
1. Failure to escalate NEWS2 scores and abnormal vital observations
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 3
1. Action
  Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.
  Stated by Holy Cross HospitalStated planned
2. Action
  Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.
  Stated by Holy Cross HospitalStated in progress
3. Action
  Train staff on the Managing a Deteriorating Patient policy after implementation.
  Stated by Holy Cross HospitalStated planned
AI-generated summary

Richard Scott-Powell · 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

Richard Scott-Powell, aged 61, suffered a spinal cord injury after a fall at home in March 2020 and later died from COVID-19 pneumonia at Holy Cross Hospital on 18 January 2021. The principal concerns were the lack of recorded escalation of high NEWS2 scores and abnormal vital signs, incomplete recording of observations, and uncertainty about whether appropriate policies and training were in place for taking, recording and escalating vital observations.

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 escalate NEWS2 scores and abnormal vital observations
Wider context from the report
“The court heard evidence that following Mr Scott-Powell’s positive COVID-19 test on 11 January 2021 a NEWS2 Observation Chart was commenced on 13 January 2021. On that day he initially had a NEWS2 score of 10 and subsequently a NEWS2 score of 5. There is no clear evidence in the hospital records to show that these scores prompted an increased level of frequency of observations or that they were escalated, whether that be to Mr Scott-Powell’s GP or otherwise. Thereafter, there are no further NEWS2 charts in Mr Scott-Powell’s records, albeit some of his vital signs are recorded in the daily notes. On a number of occasions, the notes only record that ‘vital signs are okay’ without specifying what the vital signs actually were. In respect of some of the vital signs that were recorded, Dr ████████, a GP at Grayshott Surgery which is the GP Surgery for patients at Holy Cross Hospital, gave evidence that some of them fell outside normal or expected parameters. Again, there is no evidence in the notes to show that these observations were escalated prior to Mr Scott-Powell’s death. Given Mr Scott-Powell’s pre-existing conditions and vulnerabilities the Court was not persuaded, on the balance of probabilities, that any escalation would have resulted in treatment, which would have materially improved Mr Scott-Powell’s clinical progress. 1. There is no recorded escalation of Mr Scott-Powell’s NEWS2 scores on 13 January 2021; 2. During the period from 14 January 2021 onwards, only some of his vital signs are recorded, some of which fall outside normal parameters. There is no recorded escalation of these observations in the record. 3. During the period from 14 January 2021 onwards, a number of entries record that his vital signs were okay without detailing the actual outcome of those observations. The Coroner is concerned this may not be a safe practice in that it makes it difficult for the clinical team to track progress and identify any trends. Dr ████████, a Consultant in Rehabilitation Medicine at Holy Cross Hospital and Dr ████████, GP, both attended Court to give evidence and whilst they did their best to assist the Court on these matters, it remains unclear to the Court as to whether there are sufficient and appropriate policies are in place, which are well understood by the staff, in relation to the taking, recording and escalation of vital observations at Holy Cross Hospital. Accordingly, the Coroner considers that a review of these matters should be carried out to identify whether additional policies/procedures and or/training is required. ”
Source location
Richard Scott-Powell · Prevention of Future Deaths report
Page 4 · 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
Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.

Verbatim wording from the response
“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location
Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022
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
Repeat clinical decision-making, patient-risk, NEWS2 and sepsis training for relevant ward staff.

Verbatim wording from the response
“Training (clinical decision making / patients at risk) - As part of a wider range of learning and development courses, training is provided to the ward team to facilitate clinical decision-making and escalation as follows: Clinical Decision Making (Registered Nurses), Identifying Patients at Risk (Health Care Assistants), NEWS2 (Registered Nurses and HCAs) and Sepsis (Registered Nurses and HCAs). The first two courses are in-house, with NEWS2 and Sepsis being online courses (containing standard methodologies/protocols). We are in the process of repeating training in these areas for all relevant staff.”

Source location
Response from Holy Cross Hospital
Page 1 · response
Published 27 April 2022
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
Train staff on the Managing a Deteriorating Patient policy after implementation.

Verbatim wording from the response
“• have written a policy on ‘Managing a Deteriorating Patient’, which includes a decision tree for monitoring and escalation. The policy proposes collecting regular NEWS2 baseline data for each Holy Cross patient, taking into account that many patients will routinely fall outside of the normal range. The draft policy has been reviewed by our Consultant in Rehabilitation Medicine and by the lead duty doctor to Holy Cross (from Grayshott surgery), ahead of adoption by our Clinical Governance Medical Research and Ethics Committee on 25th July. Following its implementation, the policy will be subject to review and evaluation. Staff will receive training on the policy.”

Source location
Response from Holy Cross Hospital
Page 2 · response
Published 27 April 2022
Open published response
28 Feb2022
Inner North London
Concerns raised1
1. Failure to provide an electronic paediatric early warning score and recording system
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 3
1. Action
  Implement interim electronic capture of paediatric early warning scores on the existing clinical system.
  Stated by King'S College Hospital NHS Foundation TrustStated planned
2. Action
  Implement the fully integrated Epic electronic patient record with a customised paediatric early warning score.
  Stated by King'S College Hospital NHS Foundation TrustStated planned
3. Action
  Develop and support training for rollout of electronic paediatric early warning scores, including the parental-concern trigger.
  Stated by King'S College Hospital NHS Foundation TrustStated in progress
AI-generated summary

Martha Poppy MILLS · 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

Martha sustained a handlebar injury while cycling on a family holiday in Wales, was transferred to King’s College Hospital London, and died approximately one month later from refractory shock, sepsis, pancreatic transection and abdominal trauma. At King’s, she was not referred promptly to paediatric intensivists; concerns also included the paper-based paediatric early warning score system and stalled plans to improve coordination between paediatric hepatology and intensive care.

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 provide an electronic paediatric early warning score and recording system
Wider context from the report
“1. I heard that the bedside paediatric early warning score (BPEWS) system at King’s is currently still paper based, unlike the adult system. It was put to me very forcefully by medical staff that, until the PEWS system moves to an electronic base as part of electronic recording of the paediatric records as a whole, monitoring and care of children may be sub optimal, with a higher risk of this sort of situation recurring. ”
Source location
Martha Poppy MILLS · 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 interim electronic capture of paediatric early warning scores on the existing clinical system.

Verbatim wording from the response
“The Trust has very recently committed to the implementation of a fully integrated electronic patient record system (Epic) which will replace the vast majority of existing clinical IT systems in late 2023 and will provide a customised early warning score for paediatrics. However as an interim measure, with support from our in-house clinical IT support teams, we have now developed a way of capturing paediatric early warning scores on our existing electronic system. This will support clinical teams to capture all relevant observations, highlight patients at risk (to those at the bedside and those monitoring the wards overall), and ensure that the team can document what has been done to treat/escalate based on the score.”

Source location
2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022
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 fully integrated Epic electronic patient record with a customised paediatric early warning score.

Verbatim wording from the response
“The Trust has very recently committed to the implementation of a fully integrated electronic patient record system (Epic) which will replace the vast majority of existing clinical IT systems in late 2023 and will provide a customised early warning score for paediatrics. However as an interim measure, with support from our in-house clinical IT support teams, we have now developed a way of capturing paediatric early warning scores on our existing electronic system. This will support clinical teams to capture all relevant observations, highlight patients at risk (to those at the bedside and those monitoring the wards overall), and ensure that the team can document what has been done to treat/escalate based on the score.”

Source location
2022-0063-Response-from-Kings-College-Hospital_Published
Page 3 · response
Published 3 March 2022
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
Develop and support training for rollout of electronic paediatric early warning scores, including the parental-concern trigger.

Verbatim wording from the response
“Further training is being developed to support roll out of electronic PEWS, which include the parental concern trigger. The education team are part of the working group and will be supporting the roll out in June.”

Source location
2022-0063-Response-from-Kings-College-Hospital_Published
Page 4 · response
Published 3 March 2022
Open published response
15 Feb2022
Hertfordshire
Concerns raised2
1. Failure to calculate NEWS accurately
2. Failure to document NEWS accurately
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.

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

David Clark · 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

David Clark died at Lister Hospital on 5 January 2020 after being readmitted in a drowsy state and in respiratory failure. The report identified concerns that his worsening condition was not accurately assessed or escalated appropriately, NEWS were not calculated or documented accurately, and his treatment was poorly documented. It was unclear whether these matters contributed to his 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 calculate NEWS accurately
Wider context from the report
“(2) That NEWS were not being calculated or documented accurately. ”
Source location
David Clark · 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 document NEWS accurately
Wider context from the report
“(2) That NEWS were not being calculated or documented accurately. ”
Source location
David Clark · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Jul2021
Inner North London
Concerns raised1
1. Failure to undertake further observations at intervals guided by the NEWS2 scoring system
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 3
1. Action
  Use NEWS2 to support identification of deteriorating patients and clinical decision-making.
  Stated by Practice Plus GroupStated completed
2. Action
  Deliver a service-improvement programme at HMP Pentonville to embed appropriate NEWS2 use, including deteriorating-patient training and distribution of quick-reference cards.
  Stated by Practice Plus GroupStated planned
3. Action
  Develop and communicate guidance for monitoring patients who test positive for COVID-19 in custodial settings.
  Stated by Practice Plus GroupStated completed
AI-generated summary

Mr Khairul Rahman · 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

Mr Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.

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 undertake further observations at intervals guided by the NEWS2 scoring system
Wider context from the report
“1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered; 2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern. The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover. Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting. ”
Source location
Mr Khairul Rahman · 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
Use NEWS2 to support identification of deteriorating patients and clinical decision-making.

Verbatim wording from the response
“Practice Plus Group currently adopts the NEWS2 tool to support identification of the deteriorating patient, in order to aid clinical decision making.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 3 · response
Published 9 July 2021
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 a service-improvement programme at HMP Pentonville to embed appropriate NEWS2 use, including deteriorating-patient training and distribution of quick-reference cards.

Verbatim wording from the response
“Practice Plus Group recognises the importance of NEWS2 scoring to identify potential clinical deterioration and have begun a service improvement project to encourage the appropriate use of the tool and embedding this into practice. A ‘Back to Basics’ workshop has been designed to ‘Identify the Deteriorating Patient’ and ensure escalation of clinical abnormalities. This will be delivered for the healthcare team at HMP Pentonville by 30th November 2021. Within the delivery of the training, small laminated NEWS2 cards will be distributed as an immediate ‘go to guide’ to help support implementing the use of the NEWS2 within clinical assessment and identifying the deteriorating patient.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 4 · response
Published 9 July 2021
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
Develop and communicate guidance for monitoring patients who test positive for COVID-19 in custodial settings.

Verbatim wording from the response
“It is important to note that at the time of Mr Rahman’s death there was no clinical guidance produced by NHS England to guide staff around the Management of COVID positive patients in a prison setting. In November 2020, Practice Plus Group developed the ‘Monitoring of patients who test positive for COVID’ Policy and this was updated and communicated to all staff by email”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 3 · response
Published 9 July 2021
Open published response
8 Mar2021
Mid Kent and Medway
Concerns raised1
1. Failure to undertake required patient observations
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 1
1. Action
  Implement electronic inpatient observations with NEWS2-based red-flag escalation through the networked Extremad system.
  Stated by Medway NHS Foundation TrustStated completed
AI-generated summary

Rodney Gates · 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

Rodney Gates, aged 84, was struck by an HGV while crossing a road and sustained a fracture of the right proximal femur. He deteriorated from bleeding while on a hospital ward and died on 6 April 2018 despite treatment and resuscitation attempts. Concerns included missed clinical observations, low nursing staffing levels, reliance on agency nurses, limited staff experience and skills, and insufficient equipment.

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 undertake required patient observations
Wider context from the report
“(1) the failure to undertake at all the required observations of a patient pursuant to clinical direction and / or the NEWS protocol which was directly attributable to the conditions of the nursing staff on the ward, those being - ”
Source location
Rodney Gates · 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 electronic inpatient observations with NEWS2-based red-flag escalation through the networked Extremad system.

Verbatim wording from the response
“• Since the index events in April 2018, every inpatient ward area at the Trust has moved to electronic observation recording and an effective red flagging system based on NEWS2 via our networked Extremad system”

Source location
2021-0070-Response-from-Medway-Maritime-Hospital-Redacted
Page 1 · response
Published 12 March 2021
Open published response
22 Apr2020
Manchester South
Concerns raised2
1. Inaccurate or lacking recording of clinical observations and NEWS scores
2. Inadequate action on clinical observations and NEWS scores
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 5
1. Action
  Reinforce accurate NEWS2 completion and documentation through staff communication and regular supervision.
  Stated by Pennine Care NHS Foundation TrustStated completed
2. Action
  Audit five randomly selected NEWS2 charts monthly to oversee compliance with documentation standards.
  Stated by Pennine Care NHS Foundation TrustStated completed
3. Action
  Provide rolling NEWS2 training covering accurate scoring, escalation, clinical deterioration and sepsis recognition.
  Stated by Pennine Care NHS Foundation TrustStated completed
1. Action
  Progress an agreement with the Digital Health Team to provide specialist physical-health advice to inpatient clinical teams.
  Stated by Pennine Care NHS Foundation TrustStated in progress
2. Action
  Provide Acute Illness Management training for registered and unregistered nursing staff on assessing and responding to deteriorating patients, including oxygen therapy.
  Stated by Pennine Care NHS Foundation TrustStated completed
AI-generated summary

ALLAN WILLIAM CUNLIFFE · 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

Allan Cunliffe, who had bowel problems and mental health issues, became ill on Summers Ward on 17 July 2018 and died in A&E on 18 July 2018 after deterioration associated with a perforated bowel and sepsis. The substantive concerns included poor communication, inadequate recording and calculation of NEWS scores, failures to follow observation protocols, and confusion about oxygen administration, with the jury stating that insufficient record keeping and communication probably led to an avoidable 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
Inaccurate or lacking recording of clinical observations and NEWS scores
Wider context from the report
“(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training. ”
Source location
ALLAN WILLIAM CUNLIFFE · 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
Inadequate action on clinical observations and NEWS scores
Wider context from the report
“(1) Pennine Care NHS Foundation Trust. The physical care of vulnerable patients on Summers Ward was poor. Whilst the experience of different junior doctors will inevitably vary, communication between the doctors and nurses was poor and the recording of clinical observations/ NEWS score and action thereon (designed to alleviate some of the clinical decision making) was inaccurate/ lacking. There was further confusion regarding the administration of oxygen, with at least one nurse being apparently unaware of the mandatory training. ”
Source location
ALLAN WILLIAM CUNLIFFE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reinforce accurate NEWS2 completion and documentation through staff communication and regular supervision.

Verbatim wording from the response
“Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:”

Source location
2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Page 2 · response
Published 18 May 2020
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 five randomly selected NEWS2 charts monthly to oversee compliance with documentation standards.

Verbatim wording from the response
“Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:”

Source location
2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Page 2 · response
Published 18 May 2020
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 rolling NEWS2 training covering accurate scoring, escalation, clinical deterioration and sepsis recognition.

Verbatim wording from the response
“Following Mr Cunliffe’s passing, and the conclusion at HM Coroner’s Inquest, work has been undertaken within the Older Adult’s In-Patient Service in Tameside. A ████████ o all staff members reiterating the importance of ensuring that [redacted text]culated accurately and signed appropriately. All refusals of [redacted text]tion of concern must be documented clearly in the patient’s records. This is now discussed regularly in individual team member’s supervision. In addition to this the ward manager or physical health lead now completes a monthly audit of five randomly selected NEWS2 charts. This allows oversight and assurance ████████ standards are maintained. NEWS2 training is now provided by the modern matron on a rolling programme. This training details the history of the NEWS and the importance of completing this in full. Staff are informed that the early warning system can:”

Source location
2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Page 2 · response
Published 18 May 2020
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
Progress an agreement with the Digital Health Team to provide specialist physical-health advice to inpatient clinical teams.

Verbatim wording from the response
“In addition to the above a series of meetings have taken place this year between the Older People’s Mental Health Service and the Digital Health Team which is part of Tameside Integrated Care Foundation Trust (ICFT) to explore ways of providing a holistic and consistent approach to accessing timely specialist advice in relation to the physical health needs of older people on the inpatient mental health unit at Tameside Hospital who often have complex co-morbid physical and mental health needs.”

Source location
2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Page 2 · response
Published 18 May 2020
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 Acute Illness Management training for registered and unregistered nursing staff on assessing and responding to deteriorating patients, including oxygen therapy.

Verbatim wording from the response
“More recently Pennine Care now also provides Acute Illness Management training for both registered and unregistered nursing staff. A workshop covering the systematic approach to assessing a deteriorating patient is delivered. During this airways and breathing are discussed and includes how to assess, and take action (inclusive of oxygen), in the event of an emergency. A demonstration/simulation is also delivered. The course details why a person needs oxygen to survive and the consequences of our body not receiving enough whilst also detailing normal and abnormal signs relating to the airway and breathing.”

Source location
2020-0099-Response-from-Pennine-Care-NHS-Foundation-Trust_Redacted
Page 3 · response
Published 18 May 2020
Open published response
20 Dec2019
Blackpool and the Fylde
Concerns raised1
1. Failure to monitor observations hourly for patients with a NEWS score greater than 5
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.

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

Matthew James Rogers · 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

Matthew James Rogers, aged 31, was admitted to hospital with worsening pain, weakness and lethargy and subsequently developed multiple organ injury before dying on 11 July 2019. His observations were not recorded for two and a half hours despite a NEWS score above 5, amid staffing levels below the planned establishment. The investigation report did not explain how the Trust intended to address omissions of care arising from understaffing.

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 monitor observations hourly for patients with a NEWS score greater than 5
Wider context from the report
“The Serious Incident Investigation Report set out that the patient's observations were not monitored on an hourly basis in accordance with the Royal College of Physician's guidance for frequency of observations for a patient with a NEWS score of greater than 5. It was noted in the report that Mr Rogers did not have a set of observations recorded for two and a half hours from 03:30 to 06:00. Whilst it was not clear why this omission in care occurred, it was felt likely that this occurred because of understaffing of nurses compounded by the large number of patients within the department. It was reported to me that the nurse staff levels were below template for the night shift. The staffing establishment was for 10 Registered Nurses. At the time in question six substantive Registered Nurses were on duty, plus one agency Emergency Department Registered Nurse. There were no Twilight Nurses or Long Day Registered Nurses. The Serious Incident Investigation Report did not address how these problems were proposed to be resolved by the Trust and what processes were being put in place to address the issue of omission of care arising from understaffing. ”
Source location
Matthew James Rogers · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Oct2019
Bedfordshire and Luton
Concerns raised1
1. Failure to accurately record NEWS observations and scores
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 1
1. Action
  Remind nurses to assess, score and accurately record patients’ overall observations, including confusion.
  Stated by The TrustStated planned
Respondent positions 1
1. Position
  Omitting the confusion score caused no adverse outcome because deterioration was recognised and escalated promptly.
  Stated by The TrustDisputes the concern
AI-generated summary

Pamela Evans · 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

Pamela Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s serious incident investigation.

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 record NEWS observations and scores
Wider context from the report
“(iv) Incorrect recording of this patient’s NEWS and associated score after her fall which could in other circumstances influence whether/when potentially life-saving measures for future patients take place. Significantly, the deceased’s confusion at some point after 0500 should have been recorded as 3 under D (“consciousness”) but was never noted at all. It was not clear why; the cardiac nurse practitioner was aware of it and thought the clinical support worker completing the chart had been made aware. Further: first, vomiting after 0500 should have given a nausea score of 2 but was only scored 1; secondly, while a heart rate of 160 after 0500 was noted in the nursing records, only 93 was recorded in the NEWS observation chart at 0515. ”
Source location
Pamela Evans · 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
Remind nurses to assess, score and accurately record patients’ overall observations, including confusion.

Verbatim wording from the response
“Calculating consciousness in NEWS2 I understand during the live evidence you heard that the NEWS2 algorithm now includes the status of ‘new confusion’ as an additional scoring metric and that while the notes recorded Mrs Evans had a degree of confusion, this was omitted on the scoring sheet leading to an inaccurate calculation.”

Source location
2019-0333-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 10 November 2019
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
Omitting the confusion score caused no adverse outcome because deterioration was recognised and escalated promptly.

Verbatim wording from the response
“Calculating consciousness in NEWS2 I understand during the live evidence you heard that the NEWS2 algorithm now includes the status of ‘new confusion’ as an additional scoring metric and that while the notes recorded Mrs Evans had a degree of confusion, this was omitted on the scoring sheet leading to an inaccurate calculation.”

Source location
2019-0333-Response-by-Bedford-Hospital-NHS-Trust
Page 3 · response
Published 10 November 2019
Open published response
24 Sep2019
South Wales Central
Concerns raised2
1. Failure to perform NEWS observations on time
2. Failure to complete NEWS chart fields correctly
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.
AI-generated summary

Annette Susan HEWINS · 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

Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.

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 perform NEWS observations on time
Wider context from the report
“(3) Missed Observations – It transpired that NEWS observations ought to have been undertaken at around 7.30am on 8.2.17. There was no record that they had. Whilst there appeared to be systems in place to prompt Nurses/HCA’s to undertake the observations on time – enhanced observations recorded on a white board & the NEWS charts of those patients receiving enhanced observations being separated on the Nursing station, these did not achieve the desired outcome here. It is suggested that more robust ( possibly linked to FACE) procedures should be considered to ensure the observations are performed on time ”
Source location
Annette Susan HEWINS · 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 complete NEWS chart fields correctly
Wider context from the report
“(2) Erroneously completed NEWS charts – it transpired that Nursing Staff/HCA’s were using the frequency of observation box, to record the time observations were carried out. This may require guidance/training to remind staff completing the NEWS charts of the importance of ensuring the appropriate boxes are completed. ”
Source location
Annette Susan HEWINS · 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 raised1

Failure to escalate monitoring in accordance with the NEWS policy

Concerns raised1

Failure to escalate NEWS2 scores and abnormal vital observations

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 raised1

Failure to provide an electronic paediatric early warning score and recording 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.3

Concerns raised2

Failure to calculate NEWS accurately

Failure to document NEWS accurately

Concerns raised1

Failure to undertake further observations at intervals guided by the NEWS2 scoring 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.3

Concerns raised1

Failure to undertake required patient observations

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

Concerns raised2

Inaccurate or lacking recording of clinical observations and NEWS scores

Inadequate action on clinical observations and NEWS 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.5

Concerns raised1

Failure to monitor observations hourly for patients with a NEWS score greater than 5

Actions described in response 3

Actions described in response 3

Actions described in response 3

Actions described in response 1

Actions described in response 5