Recurring concern

Unreliable clinical Early Warning Score systems for deterioration

First to latest report 24 Sep 2013 — 5 Feb 2026

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

What this concern includes

Includes failures to obtain, record or repeat required EWS observations; calculate scores accurately; make charts and scores accessible; define monitoring intervals; and initiate review or escalation required by EWS or NEWS thresholds.

What is not included

Excludes physiological monitoring that is not part of an Early Warning Score system.
Excludes failures after a score has been correctly calculated, made available and escalated according to the applicable EWS protocol.
Excludes fetal CTG, condition-specific monitoring and non-clinical scoring tools.

Trends

Reports over time

Reports mentioning this concern, 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

Reports and published responses 67 reports

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

24 Apr2019
Brighton and Hove
Concerns raised2
1. Failure to accurately and contemporaneously record NEWS observations
2. Failure to act on NEWS observations and escalate deteriorating patients
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals Sussex NHS Foundation Trust
Stated actions 2
1. University Hospitals Sussex NHS Foundation Trust
  Roll out an electronic system for recording NEWS observations and nursing assessments.
2. University Hospitals Sussex NHS Foundation Trust
  Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.
AI-generated summary

Ioannis AVGOUSTI · 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

Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

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 and contemporaneously record NEWS observations
Wider context from the report
“(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”
Source location
Ioannis AVGOUSTI · 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 NEWS observations and escalate deteriorating patients
Wider context from the report
“(2) On the 6th October 2018 although the hospital had noted that he was allergic to Co-Amoxiclav and although the paper medication notes noted that fact he was written up for that medication and it was administered to him. I saw evidence of a poorly documented, from the point of view of time, NEWS observation. Although at the top of the chart there were the numbers 2 0 (20) I found on the balance of probabilities that set of observations had more likely been taken at about 20:10 or 20:15 hours. The observations were added up to 9. In fact the total was 13. NEWS is a tool to ensure that the deteriorating patient is recognised and given help and escalated, if appropriate, to Intensive Care. This set of observations was not acted on in accordance with the directions and no escalation was made. There should have been a MET call then i.e., at around 20:15 hours to a specialist registrar (there was one on duty) If this call had been made and if the appropriate doctor had been called to see Mr. Avgousti it is possible that although the sepsis protocol would I believe have been implemented, it would have been realised that he had an allergy to Co-Amoxiclav and he would have been given an appropriate alternative. Whilst I cannot say categorically that this would have been the case I believe it is highly likely. NEWS is an important tool and should not be ignored as it was on Vallance Ward on the night of the 6th October 2018. ”
Source location
Ioannis AVGOUSTI · 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 an electronic system for recording NEWS observations and nursing assessments.

Verbatim wording from the response
“I agree with you that NEWS is a very important tool and should be used and followed correctly. I regret the NEWS documentation was not to the standard we expect. The ward team have reflected at length and the case was discussed by the wider team at the Medicine Division’s Clinical Governance meeting on 17 May 2019. I am pleased to say, after a successful trial, the Trust has purchased an electronic system for recording NEWS and nursing assessments. This system is currently rolling out electronic recording of observations, and NEWS scores of all patients will therefore be available to view by the”

Source location
2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Page 2 · response
Published 14 June 2019
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
Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.

Verbatim wording from the response
“Critical Care Outreach service, of which we are expanding, so escalation will be immediate rather than reliant on staff on the ward calculating the scores and putting out a MET call.”

Source location
2019-0135-Response-by-Brighton-and-Sussex-University-Hospitals
Page 3 · response
Published 14 June 2019
Open published response
5 Feb2019
Bedfordshire and Luton
Concerns raised1
1. Failure to act on NEWS scores in accordance with the NEWS Protocol
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Gwyneth Ann EDWARDS · 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

Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.

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 in accordance with the NEWS Protocol
Wider context from the report
“(2) The SIR recommended that laminated cards be given to staff with National Early Warning Score (NEWS) scoring and response guidance. It is clear from the evidence of the nurses at the Inquest that the NEWS scoring was being recorded, but not actioned in accordance with the NEWS Protocol. This would suggest that the SIR recommendations to re-inforce learning is not effective. ”
Source location
Gwyneth Ann EDWARDS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jan2019
Manchester South
Concerns raised1
1. Failure to complete and repeat EWS observations at required intervals
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions 4
1. Tameside and Glossop Integrated Care NHS Foundation Trust
  Communicated theatre documentation and NEWS escalation expectations through a team meeting and staff memo.
2. Tameside and Glossop Integrated Care NHS Foundation Trust
  Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
3. Tameside and Glossop Integrated Care NHS Foundation Trust
  Distributed a Trust-wide learning bulletin on completing, recording and escalating NEWS observations.
1. Tameside and Glossop Integrated Care NHS Foundation Trust
  Implemented NEWS2, including revised observation and escalation processes and associated staff training.
AI-generated summary

Michael William Flynn · 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

Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete and repeat EWS observations at required intervals
Wider context from the report
“3. His final two EWS scores did not include all relevant information despite a visibly clinically deteriorating position. His penultimate EWS was recorded at midnight. That was five (and did not include blood pressure). A further score should have been taken 15-30 minutes later. It was not and no further scores were taken for a further 4 hours and 50 minutes. At 04.50 his score was recorded at 10. He then became unresponsive. ”
Source location
Michael William Flynn · 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
Communicated theatre documentation and NEWS escalation expectations through a team meeting and staff memo.

Verbatim wording from the response
“For your further assurance, your concerns were raised and discussed directly with clinical teams at the Theatre team meeting on 29 January 2019. I am informed that the Matron for Theatres subsequently issued a memo to all theatre nursing staff detailing the concerns raised and the expectations on staff of ensuring recovery documentation is comprehensive and complete and that optimal NEWS scores are achieved prior to transfer of patients to the ward, or increased NEWS scores escalated appropriately to the anaesthetist prior to transfer.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 2 · response
Published 23 May 2019
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
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.

Verbatim wording from the response
“The Matron for the Orthopaedic Unit has provided assurances that formal discussions have taken place with the nursing staff identified through our investigation as failing to comply with Trust Policy in respect to the regularity, recording and appropriate escalation of NEWS observations, and consideration given to identified support or training needs. Additionally, I understand the ward manager has circulated a newsletter to all staff reiterating their responsibilities and accountability with regards to the appropriate recording and escalation of NEWS, including -”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 2 · response
Published 23 May 2019
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
Distributed a Trust-wide learning bulletin on completing, recording and escalating NEWS observations.

Verbatim wording from the response
“To provide assurances that the learning from this case is shared Trust wide I am aware that the Trust Patient Safety Team have drafted and distributed a ‘Time out for Learning’ bulletin focusing on the importance of completing, recording and escalating NEWS observations appropriately.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 3 · response
Published 23 May 2019
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
Implemented NEWS2, including revised observation and escalation processes and associated staff training.

Verbatim wording from the response
“Although not directly relevant in the context of this Regulation 28 Report, I would like to advise you of a change made within the Trust relating to the National Early Warning Score (NEWS). At the time of Mr. Flynn’s episode of care, the Trust were using a modified/adapted NEWS tool, which had been in use since 2014. In 2018, a Patient Safety Alert was published requiring Trusts to adopt a revised National Early Warning Score (NEWS2) drafted by the Royal College of Physicians. The alert resulted from the recognition that healthcare providers used a variety of adapted NEWS or locally devised early warning scores, increasing the risk of harm resulting from having different scoring systems in use across the NHS when patients or staff move between services.”

Source location
2019-0008-Response-by-Tameside-and-Glossop-Care-NHS-Trust
Page 3 · response
Published 23 May 2019
Open published response
21 Dec2018
Norfolk
Concerns raised3
1. Incorrect completion of early warning score documentation
2. Failure to escalate treatment when early warning scores require it
3. Inconsistent completion and scoring of early warning scores across departments
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

William Clifford ATHERTON · 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

William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

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
Incorrect completion of early warning score documentation
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to escalate treatment when early warning scores require it
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · 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
Inconsistent completion and scoring of early warning scores across departments
Wider context from the report
“That no medical review of Mr Atherton took place after the ward round on 30th. That his worsening condition was not recognised by the junior doctor reviewing the blood results. That no nursing observations were carried out in the several hours whilst he waited to go home and that potential warning signs of a bowel obstruction were not recognised and acted upon. His documentation was incorrectly filled in (early warning scores EWS) and thus the proper escalation of treatment which this should have triggered did not take place. That the different department at QEH appear to complete EWS differently results in inconsistent scoring and the potential to not escalate treatment of a patient who needs it. ”
Source location
William Clifford ATHERTON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Nov2018
Manchester North
Concerns raised1
1. Incorrect calculation of NEWS scores
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Lea · 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

John Lea was admitted to hospital for management of heart failure and was later found collapsed on the ward after the bay-tagging nurse temporarily left without arranging monitoring. Resuscitation was unsuccessful and his death was confirmed on 12 June 2017; the report considered a sudden cardiac-related event more likely than not. Concerns included incomplete risk assessments, poor communication, gaps in documentation, failure to escalate a change in oxygen saturations, incorrectly calculated NEWS scores, and failures to follow relevant policies and protocols.

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
Incorrect calculation of NEWS scores
Wider context from the report
“5. Incorrectly calculated NEWS scores. The NEWS was designed to address mistakes brought about by the previous early waring score tool (EWS), yet mistakes with regard to score calculations continue. ”
Source location
John Lea · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Nov2018
South Yorkshire (Eastern)
Concerns raised1
1. Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Roy Burgess · 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

Roy Burgess, aged 87, was admitted after a fall at home that caused a left femoral fracture and was transferred for surgery. The report identified missed opportunities to recognise and escalate his deteriorating condition, inadequate clinical record-keeping, and untimed ward-round notes entered non-chronologically. The inquest concluded that it was unlikely that intervention would have altered the outcome.

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 adhere to the Early Warning System for identifying and escalating deteriorating patients
Wider context from the report
“(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management. ”
Source location
Roy Burgess · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Oct2018
Liverpool and the Wirral
Concerns raised1
1. Failure to repeat observations hourly in accordance with the NEWS policy
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Tom Cribley · 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

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

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 repeat observations hourly in accordance with the NEWS policy
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
9 May2018
Norfolk
Concerns raised2
1. Failure to escalate EWS scores of 3 for medical review and increased observations
2. Failure to assess and record Early Warning Scores three times per day
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Stated actions 4
1. the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
  Provide staff with support to understand and use the current escalation system.
2. the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
  Implement NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.
3. the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
  Appoint a NEWS2 Champion.
1. the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
  Conduct ongoing audits of NEWS2 documentation and escalation.
Respondent positions 1
1. the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
  Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.
  Unable to act
AI-generated summary

KIRSTY ELIZABETH TOLLEY · 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

Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.

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 EWS scores of 3 for medical review and increased observations
Wider context from the report
“(3) Evidence was heard that if EWS reaches 3, then this should be escalated to a doctor who should review the patient and set a plan. Observations should be increased to 4 times per hour with further review. The EWS reached 3 on 4 occasions (including the occasion when the EWS was not completed in the records – 17 February) and there is no evidence that any additional action was taken. In particular on the 17 February no observations/EWS for over 17 hours. ”
Source location
KIRSTY ELIZABETH TOLLEY · 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 assess and record Early Warning Scores three times per day
Wider context from the report
“(2) Early Warning Scores (EWS) are required to be assessed and recorded 3 times per day. This was not done at lunchtime on 11 February nor evening time on 17 February 2017. No reason has been given for this. ”
Source location
KIRSTY ELIZABETH TOLLEY · 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
Provide staff with support to understand and use the current escalation system.

Verbatim wording from the response
“The staff, both nursing and medical, working in that clinical area have received support to ensure that they understand and are able to use the current escalation system.”

Source location
2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Page 2 · response
Published 1 July 2018
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 NEWS2 with new documentation, training and escalation procedures, supported by communications and a November 2018 go-live.

Verbatim wording from the response
“The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

Source location
2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Page 2 · response
Published 1 July 2018
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
Appoint a NEWS2 Champion.

Verbatim wording from the response
“May 16 Appointment of NEWS2 Champion”

Source location
2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Page 2 · response
Published 1 July 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Conduct ongoing audits of NEWS2 documentation and escalation.

Verbatim wording from the response
“This will be followed by an ongoing audit to ensure appropriate documentation and audit of escalation.”

Source location
2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Page 2 · response
Published 1 July 2018
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
Widespread retraining on older escalation procedures will not occur before NEWS2 implementation because it could cause confusion.

Verbatim wording from the response
“The Trust has therefore decided to bring forward plans to adopt the National Early Warning system (NEWS2) that is mandated across the NHS from April 2019 and will implement this on November 1st 2018.”

Source location
2018-0139-Response-by-Queens-Elizabeth-Hospital-Kings-Lynn
Page 2 · response
Published 1 July 2018
Open published response
12 Apr2018
Sunderland
Concerns raised1
1. Lack of an effective observation-based early warning system
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Hc-One Limited
Stated actions 2
1. Hc-One Limited
  Train nurses and senior care staff in the NEWS early-warning system and deliver the training to care staff.
2. Hc-One Limited
  Embed Resident of the Day quality-assurance reviews to identify changes or deterioration and monitor care and support needs.
Respondent positions 1
1. Hc-One Limited
  Terminological differences cannot all be removed and are not necessarily inappropriate, although consistent language and indicators are important.
  Disputes the concern
AI-generated summary

Patricia Ann Heslop · 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

Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

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
Lack of an effective observation-based early warning system
Wider context from the report
“3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations. ”
Source location
Patricia Ann Heslop · 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
Train nurses and senior care staff in the NEWS early-warning system and deliver the training to care staff.

Verbatim wording from the response
“3.2 Evidence was heard during the inquest of the increased use of NEWS early warning system to enable observations to be obtained. NEWS is a well validated ‘track and trigger’ early warning score system used in the majority of UK hospitals. It is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present or are being monitored in healthcare settings. Use of NEWS score assist in the identification of a sick patient. Evidence was provided that staff at Hebburn Court have now been trained in the NEWS system. All nurses and senior care staff have received training in the system and this will also then be delivered to care staff over the coming few months.”

Source location
2018-0102-Response-by-HC-One
Page 5 · response
Published 17 June 2018
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Embed Resident of the Day quality-assurance reviews to identify changes or deterioration and monitor care and support needs.

Verbatim wording from the response
“6.1 Evidence was heard during the inquest that the delay in obtaining treatment, whilst did not directly contribute to the death, did result in Mrs. Heslop being in pain for a longer period than necessary. This can be attributed to by carers and nursing staff not appropriately recognising and acting upon indicators of deterioration. The Resident of the Day reviews identify any changes or deterioration now that the quality assurance system has been reset and embedded at the home. This will be further enhanced by the e.care system, as mentioned previously in terms of robust monitoring and reviews of care and support needs.”

Source location
2018-0102-Response-by-HC-One
Page 7 · response
Published 17 June 2018
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
Terminological differences cannot all be removed and are not necessarily inappropriate, although consistent language and indicators are important.

Verbatim wording from the response
“3.1 You identified that a number of terms were used regarding Mrs. Heslop’s developing condition. ████████ provided evidence during the inquest that whilst it is not possible to remove all differences in clinical description (including the use of colloquialisms and staff language) to describe a resident's individual presentation nor is it necessarily appropriate to do so, it is however important to provide consistent language and indicators which can provide an early warning system based on observations.”

Source location
2018-0102-Response-by-HC-One
Page 5 · response
Published 17 June 2018
Open published response
16 Oct2017
Wiltshire and Swindon
Concerns raised1
1. Lack of guidance on the frequency of recording observations for patients scoring 7 or above on NEWS
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Great Western Hospitals NHS Foundation Trust
Stated actions 2
1. Great Western Hospitals NHS Foundation Trust
  Carry out Trust-wide quality-improvement work to improve NEWS recording accuracy and associated actions.
2. Great Western Hospitals NHS Foundation Trust
  Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.
Respondent positions 1
1. Great Western Hospitals NHS Foundation Trust
  The Trust’s policy already provides guidance requiring continuous observations and recording for patients with NEWS scores of seven or more.
  Disputes the concern
AI-generated summary

Jeremy Michael Holt · 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

Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.

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
Lack of guidance on the frequency of recording observations for patients scoring 7 or above on NEWS
Wider context from the report
“3. Recording observations in a patient scoring 7 or above – I was comfortable hearing that a monitor was connected to Dr Marshall when his NEWS score reached 7 which would record observations electronically every 15 minutes and I heard evidence that at some point in 2018 you will be moving to an electronic system. In the interim I am concerned that there is no guidance given as regards the frequency of recording the observations on an Observations Chart in respect of a patient scoring 7 above on the NEWS score. Between 2350 on 14 November 2016 and 0240 on 15 November 2016 nothing was actually recorded on the Observations Chart itself which causes me concern in the interim. I did indicate to ████████ during the course of the proceedings that I would like to come and visit once this system is in place and have a look for myself at the new software that you have in relation to NEWS scores and other new software that you have introduced in the last 18 months or so. I fully accept that there needs to be a balance as regards overburdening the nursing staff but at the same time I believe conversely that a gap of nearly 3 hours in respect of recorded observations of a critically ill patient is simply too long a gap. Should the frequency of observations be something that should automatically form part of a care plan in respect of a critically ill patient? ”
Source location
Jeremy Michael Holt · 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
Carry out Trust-wide quality-improvement work to improve NEWS recording accuracy and associated actions.

Verbatim wording from the response
“Recording observations in a patient’s NEWS is scoring 7 or more In your letter you felt there was no guidance regarding the frequency of documenting observations. The Trust has a ‘Recognition of the Deteriorating Patient’ policy and this mandates the requirements for measuring and recording of observations. The policy states that for a patient with a NEWS score of 7 or more, observations should be measured continuously and each set of observations recorded. As you heard at Dr Marshall’s inquest, the Trust will be implementing electronic observations in the early part of 2018. In the meantime there is a quality improvement piece of work across the Trust to improve the recording and actions of NEWS. Audit data shows that the NEWS accuracy is consistently over 90%.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
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
Install electronic observations with automated, sequential escalation alerts to doctors and implement the system Trust-wide.

Verbatim wording from the response
“In the New Year the Trust will be installing an electronic observations IT system. For this the Trust is developing clear algorithms to enable automatic escalation to the doctors, this will be on a loop so if for example the F2 doctors do not respond, this will be escalated to the registrars and will continue through the doctor ranks up to Consultant until someone responds to the escalation alert. I have enclosed the high level roll out plan, you will see we aim to have electronic observations implemented Trust wide by May 2018.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
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
The Trust’s policy already provides guidance requiring continuous observations and recording for patients with NEWS scores of seven or more.

Verbatim wording from the response
“Recording observations in a patient’s NEWS is scoring 7 or more In your letter you felt there was no guidance regarding the frequency of documenting observations. The Trust has a ‘Recognition of the Deteriorating Patient’ policy and this mandates the requirements for measuring and recording of observations. The policy states that for a patient with a NEWS score of 7 or more, observations should be measured continuously and each set of observations recorded. As you heard at Dr Marshall’s inquest, the Trust will be implementing electronic observations in the early part of 2018. In the meantime there is a quality improvement piece of work across the Trust to improve the recording and actions of NEWS. Audit data shows that the NEWS accuracy is consistently over 90%.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to accurately and contemporaneously record NEWS observations

Failure to act on NEWS observations and escalate deteriorating patients

Linked response

Stated actions 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 in accordance with the NEWS Protocol

Concerns raised1

Failure to complete and repeat EWS observations at required intervals

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Concerns raised3

Incorrect completion of early warning score documentation

Failure to escalate treatment when early warning scores require it

Inconsistent completion and scoring of early warning scores across departments

Concerns raised1

Incorrect calculation of NEWS scores

Concerns raised1

Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients

Concerns raised1

Failure to repeat observations hourly in accordance with the NEWS policy

Concerns raised2

Failure to escalate EWS scores of 3 for medical review and increased observations

Failure to assess and record Early Warning Scores three times per day

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 2

Stated actions 4

Stated actions 4

Respondent positions 1