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.

9 Aug2017
South Wales Central
Concerns raised1
1. Delay in acting on abnormal NEWS observations
This report raised 3 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

Dennis George Redmore · 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

Dennis George Redmore was admitted to hospital with a blocked catheter and presumed urinary tract infection while receiving palliative treatment for lymphoma. After an unwitnessed fall in hospital on 6 March 2017, he deteriorated, was found to have a subdural haematoma, and died later the following evening. The report identified gaps in neurological observations, delayed response to abnormal observations, and inadequate management to ensure checks were completed; it did not establish that these failures caused or 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
Delay in acting on abnormal NEWS observations
Wider context from the report
“(1) There where clear failures to monitor the deceased neurologically with gaps of several hours between observations. He should have been monitored every 30 minutes but was in fact, according to the evidence monitored at 20:15, 21:00, 22:00, 23:00, 01:00, 04:00, 07:30 and 08:50. “NEWS” observations were carried out and one was carried out at 06:20 on the morning of the 7th March which revealed an elevation in blood pressure and pulse. That was not acted upon for approximately another hour. The evidence suggested that the observations may have undertaken but not recorded. The clear concern is that observations were not carried out in accordance with local and national guidance. There was no clear evidence in this case that the lack of observations had in fact caused or contributed to the death of Mr Redmore but this must give rise to a concern for the welfare of others. No appropriate management of the nurse responsible for the observations was in place to ensure the checks were carried out. ”
Source location
Dennis George Redmore · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jul2017
Manchester North
Concerns raised1
1. Failure of Registered Nurses to calculate early warning scores accurately
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

Ms Edith Robinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ms Edith Robinson was admitted to Accident and Emergency after a fall, with problems identified with her prosthetic hip. Surgery was delayed and, as she deteriorated, action was not taken to rescue her; she died at Royal Oldham Hospital on 20 June 2016. The report identified concerns about weekend consultant review, early warning score calculation and use, record keeping, escalation, communication and other aspects of 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 of Registered Nurses to calculate early warning scores accurately
Wider context from the report
“2. Early Warning Scores – again, during the course of the evidence it became apparent that there were problems with the Registered Nurses' ability to calculate early warning scores accurately. As early warning scores are inextricably linked to escalation and management of the critically ill/deteriorating patient, this gives me serious cause for concern. I was told that this problem is not just a local issue, but a national issue. I am also concerned that there is over-reliance placed upon tools of this nature, rather than the exercising of clinical/professional judgement. It is not the first time that problems relating to the calculation and use of early warning scores have become apparent during the course of an inquest. ”
Source location
Ms Edith Robinson · Prevention of Future Deaths report
Page 1 · concerns
Open source report
18 May2017
London (West)
Concerns raised1
1. Failure to follow NEWS/MEWS scoring processes for identifying acutely unwell patients
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 1
1. Action
  Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.
  Stated by NHS EnglandStated in progress
AI-generated summary

Alice Amaryllis Gibson-Watt (“Alice”) · 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

Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

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 follow NEWS/MEWS scoring processes for identifying acutely unwell patients
Wider context from the report
“This is: The identification of acutely physically unwell patients being nursed in an acute mental health setting, and thereon appropriate escalation of care In Alice’s case, even before there were signs that she was physically unwell, there was no regular monitoring and documentation of physical vital signs to assist in identifying any trend/pattern in physical health. No serial measurements of her observations meant that abnormalities could not be easily, or at all, identified once they occurred. In mental health units the threshold that prompts the use of regular vital sign observations appears to be high, and there maybe good reasons for that and clearly this is a patient-specific issue. However, identification of patients who are becoming acutely physically unwell does need more attention in general, with or without reconsidering how readily vital sign observations are ordered. Even when the NEWS (previously MEWS) system is in place - a process which is there to assist in the identification of patients who are becoming acutely unwell - it is not always followed. This is a recurring theme I see as a coroner. Having policies and procedures in place does not appear to be sufficient. I am aware that Nurse Consultants in Physical Healthcare are now working in acute mental health settings. That seems like a big step in the right direction. I am told there are very few Nurse Consultants in Physical Healthcare working in mental health settings currently (maybe as few as six). I was impressed with the Nurse Consultant who currently works for the West London Mental Health NHS Trust. I am aware that remote physiological monitoring of patients in acute mental health settings has been trialled and this may assist in the future. As with the NEWS scoring system, predisposes that staff will accurately use, interpret and act upon abnormal observations appropriately. From what I have seen with the use of MEWS/NEWS scoring, this will be the challenge. Nurse Consultants in Physical Healthcare would be able to assist. ”
Source location
Alice Amaryllis Gibson-Watt (“Alice”) · 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
Continue supporting CQC inspection and regulation of mental health inpatient wards, including systems for identifying and responding to deteriorating patients.

Verbatim wording from the response
“• In parallel, NHS England continues to support the ongoing inspection and regulation of mental health in-patient wards by the CQC. CQC require that all providers implement safe and effective systems for identifying and responding to the deteriorating patient including application and audit of compliance with the National Early Warning Score- NEWS.”

Source location
2017-0163-Response-by-NHS-England
Page 2 · response
Published 17 August 2017
Open published response
20 Apr2017
South Wales Central
Concerns raised2
1. Failure to appropriately escalate care in response to deteriorating NEWS scores
2. Delays in clinical review of patients with deteriorating NEWS scores
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Harold Mullins · 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

Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

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 appropriately escalate care in response to deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Source location
Harold Mullins · 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
Delays in clinical review of patients with deteriorating NEWS scores
Wider context from the report
“(1) A review of the care that was received by Mr Mullins revealed that the surgical team were unaware of his history of deep vein thrombosis when undertaking the surgery and caring for him in general. (2) Despite a deteriorating position in relation to his observations (NEWS scores) he was not seen by a clinician in a timely fashion. There appears to be a difficulty in patients being seen in these circumstances appropriately by clinical staff which is a concern given that the purpose of the NEWS score system is to escalate care in cases of deterioration. It is a concern that the clinician contacted initially when the NEWS scores were deteriorating indicated that this was not to be expected given that he had undergone surgery. ”
Source location
Harold Mullins · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Apr2017
North West Kent
Concerns raised1
1. Deficiencies in operation of PAR scoring (now NEWS)
This report raised 3 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

Sian Marie Hollands · 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

Sian Hollands attended Darent Valley Hospital on 14 November 2015 with breathlessness and chest pain after recent surgery and possible opiate withdrawal. She was later suspected to have a pulmonary embolus, suffered a cardiac arrest, and died on 15 November 2015. The stated concerns included PAR scoring and staff training, doctors not being provided with nurses’ medical notes, and failure to correctly diagnose pulmonary embolism.

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
Deficiencies in operation of PAR scoring (now NEWS)
Wider context from the report
“(1) The operating of the PAR scoring (now NEWS) and training of nurses and doctors ”
Source location
Sian Marie Hollands · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Mar2017
South Wales Central
Concerns raised2
1. Failure to accurately calculate NEWS scores and trigger required medical review
2. Failure to continue NEWS observations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Clive Davies · 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

Clive Davies, who was generally in poor health and had a history of falls, fell down the stairs at home on 22 August 2016 and sustained serious head and neck injuries. He died in hospital on 30 August 2016; concerns included failures in routine NEWS and neurological observations, including an incorrectly calculated NEWS score and missed 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 accurately calculate NEWS scores and trigger required medical review
Wider context from the report
“(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming. ”
Source location
Clive Davies · 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 continue NEWS observations
Wider context from the report
“(1) The evidence revealed that there were generalised failures in relation to routine observations conducted upon Mr Davies – both NEWS observations and “neuro” observations. On the 29th August neuro observations were performed at 0600 hours but were then supposed to be conducted every 4 hours but were not at 10AM 2PM 6PM and 10PM. The final neuro observation was conducted at 11PM and no explanation could be found as to why this had not happened. The last NEWS score was conducted at 1745 on the 29th August but not thereafter. Upon review it appeared that that NEWS score which was undertaken was incorrectly calculated meaning that he was not subject to a medical review when clearly he should have been. It was accepted at the inquest that this was a failure for which no explanation was forthcoming. ”
Source location
Clive Davies · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Mar2017
Manchester City
Concerns raised1
1. Incorrect calculation of early warning scores
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mrs Kathleen Cooper · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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 early warning scores
Wider context from the report
“3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”
Source location
Mrs Kathleen Cooper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Nov2016
Mid Kent and Medway
Concerns raised2
1. Failure to understand the NEWS scoring system
2. Failure to apply the NEWS scoring system 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

Dennis Plater · 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

Dennis Plater died of natural causes at Medway Maritime Hospital on 3 February 2016, following deterioration associated with acute kidney injury, sepsis and metastatic lung adenocarcinoma. The report identified incomplete fluid-balance records, failures in NEWS scoring and escalation by an agency nurse, and concerns about the Trust’s monitoring of agency staff training and compliance.

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 understand the NEWS scoring system
Wider context from the report
“2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system, did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so. ”
Source location
Dennis Plater · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to apply the NEWS scoring system correctly
Wider context from the report
“2) That a patient was placed in the care of Nurse who neither understood the NEWS scoring system, did not apply it correctly and failed to escalate patient's condition in circumstances where she ought to have done so. ”
Source location
Dennis Plater · Prevention of Future Deaths report
Page 3 · concerns
Open source report
11 Oct2016
Blackpool and the Fylde
Concerns raised1
1. Failure to act on elevated National Early Warning Scores
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Barry THOMPSON · 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

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

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 elevated National Early Warning Scores
Wider context from the report
“(1) Non-compliance with National and Local protocols: Mr Thompson was triaged as a high priority on admission to the Emergency department at 12.37 am on 26th February 2016. It is recorded that he not had his morning insulin. He was not seen by a doctor nor given antibiotics within an hour according to the National Standard and the (Hospital’s) Sepsis Pathway. He was seen by a doctor at 16.52 (although his case was drawn to the attention of a doctor earlier by a nurse and instructions given for care). Further a NEWS score of 7 (National Early Warning Score) was not actioned according to policy which would have resulted in Mr Thompson being reviewed by at least middle grade doctor immediately. ”
Source location
Barry THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Aug2016
Brighton and Hove
Concerns raised3
1. Failure to use NEWS properly
2. Inaccurate NEWS scoring
3. Failure to report raised NEWS scores to doctors or critical care outreach
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 4
1. Action
  Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Disseminate National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Develop the detailed business case for investment in an electronic National Early Warning System.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
1. Action
  Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
AI-generated summary

Diana Maxine RITCHIE · 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

Diana Maxine Ritchie was recovering from major surgery when she deteriorated overnight on 5–6 March and suffered a cardiac arrest at around 12.20 hrs on 6 March. Concerns included missed opportunities to escalate care in response to raised NEWS scores, inaccurate or potentially delayed observations, and failures in the use of NEWS across the Trust.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to use NEWS properly
Wider context from the report
“(6) Finally this is not the first time I have had to write a Regulation 28 Report to this Trust which involves abuse of or failure to use NEWS properly at all. It is in my view necessary for there to be substantial and immediate training on proper use of NEWS throughout the Trust. I am told that there are electronic hand-held ‘smart’ pieces of equipment which can be used to take and record NEWS and which then omit a warning signal if the NEWS is raised. This should be considered at this hospital. I understand that Worthing Hospital (recently rated excellent by the CQC) has this handheld equipment and uses it to good effect. ”
Source location
Diana Maxine RITCHIE · 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
Inaccurate NEWS scoring
Wider context from the report
“(2) That there were missed opportunities to escalate Mrs Ritchie's treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team. There were eight different NEWS scores taken between 06.30 on the 6th and 11.15 on the 6th. On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low). One of them scored at 4 but the remainder scored at 5 and above. As I say, none of them resulted in a call to critical care outreach or to the ward SHO. ”
Source location
Diana Maxine RITCHIE · 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 report raised NEWS scores to doctors or critical care outreach
Wider context from the report
“(2) That there were missed opportunities to escalate Mrs Ritchie's treatment arising from raised NEWS scores where there was no report of those raised scores either to the doctors on the ward or to the critical care outreach team. There were eight different NEWS scores taken between 06.30 on the 6th and 11.15 on the 6th. On two of them the scoring was inaccurate (one was scored 2 points too high and the other was scored 2 points too low). One of them scored at 4 but the remainder scored at 5 and above. As I say, none of them resulted in a call to critical care outreach or to the ward SHO. ”
Source location
Diana Maxine RITCHIE · 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
Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.

Verbatim wording from the response
“I recognise, as does the Trust's Interim Chief Nurse, that accurate completion and scoring of observations on the National Early Warning charts, and appropriate escalation, is very important. In the light of these events, considerable action has been taken on the ward concerned (in conjunction with their matron) to ensure that the individuals directly caring for Mrs Ritchie, as well as the rest of the ward team, are fully familiar with what is expected of them. They have reflected carefully on this, as well as attending specific additional training since these sad events to improve their knowledge and skills. The ward action plan is being presented to the monthly adult meeting for women's services, as well as feedback being taken to the safety and quality meeting for wider learning.”

Source location
2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
Page 1 · response
Published 18 August 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Disseminate National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.

Verbatim wording from the response
“In order to extend this learning more widely, I used the Spotlight on Safety, in my weekly message to all staff, to focus on NEWS, saying - among other things - “it is vital that NEWS scores are calculated correctly and acted on appropriately if we are to provide safe care for our patients” and providing a direct link to the Trust's Patient Observation Policy.”

Source location
2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
Page 2 · response
Published 18 August 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop the detailed business case for investment in an electronic National Early Warning System.

Verbatim wording from the response
“The Trust is considering carefully the series of actions which are essential before any electronic NEWS system can be introduced. The Trust provides clinical services in a wide range of buildings - some extremely old - across several sites. As an essential preliminary step, WIFI cover is being extended to cover the whole Trust. It is anticipated that this will be in place in 2017, enabling the Trust to make further progress in automating observations. The Trust Senior Management Team has given support in principle to the introduction of an electronic NEWS system, and the detailed business case required for such an investment is actively being taken forward.”

Source location
2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
Page 2 · response
Published 18 August 2016
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.

Verbatim wording from the response
“The Trust's Patient Safety team sends a “Patients 1st” bulletin each month to all staff. This uses a fictionalized story to draw attention to things that may go wrong and sets out good practice. Since the death of Mrs Ritchie, such a bulletin has been circulated, which focused on the recognition and appropriate escalation of care for a deteriorating patient.”

Source location
2016-0296-Response-by-Brighton-and-Sussex-University-NHS-Trust
Page 2 · response
Published 18 August 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delay in acting on abnormal NEWS observations

Concerns raised1

Failure of Registered Nurses to calculate early warning scores accurately

Concerns raised1

Failure to follow NEWS/MEWS scoring processes for identifying acutely unwell patients

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

Failure to appropriately escalate care in response to deteriorating NEWS scores

Delays in clinical review of patients with deteriorating NEWS scores

Concerns raised1

Deficiencies in operation of PAR scoring (now NEWS)

Concerns raised2

Failure to accurately calculate NEWS scores and trigger required medical review

Failure to continue NEWS observations

Concerns raised1

Incorrect calculation of early warning scores

Concerns raised2

Failure to understand the NEWS scoring system

Failure to apply the NEWS scoring system correctly

Concerns raised1

Failure to act on elevated National Early Warning Scores

Concerns raised3

Failure to use NEWS properly

Inaccurate NEWS scoring

Failure to report raised NEWS scores to doctors or critical care outreach

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

Actions described in response 1

Actions described in response 4